Friday night lights are beaming bright in high school football stadiums all across the country. Players are suited up, taped up and ready to rumble in an inherently unpredictable game where anything can happen. A turnover that shifts the momentum. A missed tackle that gives up a touchdown. A Hail Mary that wins the game. In football, only one thing is for sure — the risk of injury to players.

Among all high school sports, football ranks No. 1 in injury rates, according to a study published in the Orthopaedic Journal of Sports Medicine. It’s no surprise given the nature of the game, says Dan Guzman, M.D., an emergency medicine physician at Cook Children’s Medical Center – Fort Worth.

“It's a violent sport, and we know players are trained to go out and get that ball and hit hard,” Dr. Guzman said. “So we're going to, unfortunately, have injuries as a result of that aggressive play.”

In some cases, the results are tragic.

In 2023, the National Center for Catastrophic Sports Injuries reported 16 football-related deaths in its Annual Survey of Football Injury Research. Five deaths were at the college level, seven in high school, two in middle school and two in youth league. Three deaths were directly related to football and a result of a traumatic brain injury. Ten fatalities were classified as exertional/medical fatalities, which includes sudden cardiac arrest and heatstroke, that occured during football-related activity. 

In August, National Public Radio (NPR) reported that at least seven high school and middle school football players died during that month from head injuries or suspected heatstroke.

Tackling Trauma

Dr. Guzman has seen his fair share of football-related injuries in Cook Children’s Emergency Department. Most players visit the ER for orthopedic injuries of upper or lower extremities. Dr. Guzman suggests recent efforts to protect the head and neck from traumatic injury are leading to an increase in shoulder and arm injuries. Although these injuries can be serious and lead to loss of playing time, the trade-off is necessary to decrease the risk of traumatic brain injury or concussion, and to protect more critical areas of the body. 

“Coaches are teaching kids to not use their head and neck to initiate contact and, instead, use their shoulder, so I think we've seen a slight increase in the number of shoulder and clavicle injuries and shoulder separations,” Dr. Guzman said.

Not all injuries warrant a trip to the ER, but can have just as significant out of activity implications as their more serious counterparts. Bruises, sprains and strains are some of the most frequent injuries seen in football, according to Jeffrey Bass, MS, ATC, LAT, OPE-C, a licensed and board certified athletic trainer at Cook Children’s Orthopedics and Sports Medicine Walsh Ranch. Bass is also a football medical observer in the Big 12 Conference and a regular on the sidelines at high school football games, where he’s often referred to as “Doc” while he works to protect young athletes from injury.

“It’s a term of endearment based on the fact that the athletic trainer’s work can parallel that of a physician and because they can fill many roles, especially in rural areas,” he said. “The good news is I’ve never been confused with any of our local doctors, and I’ve never been asked to operate on anyone or deliver a baby.”

With 46 years of experience in the industry, Bass knows what makes a good football program, and a focus on player safety is at the top of his list.

“We know that about 95% of participants involved in competitive athletics are going to have a time loss injury,” Bass said. “It’s not a matter of if, it’s just when.”

With the risk of injury in competitive athletics so high, especially in a full-contact sport like football, it’s important that parents know that their child’s football program is ready and equipped to respond to an injury, be it minor or severe. We asked our experts to tell us what’s most important when it comes to player safety so parents can worry less and focus more on cheering their athlete into the endzone. 

What are the most important safety elements of a football program?

Be Prepared
Texas Senate Bill 82 outlines safety regulations for public school extracurricular activities. It mandates safety training for all coaches or athletic event sponsors, along with an emergency drill incorporating this training. It also requires that student athletes be provided training in recognizing symptoms of catastrophic injuries, such as head and neck injuries, concussion, heatstroke, and more. 

The University Interscholastic League (UIL) advises that schools have a detailed emergency action plan to respond to player and spectator medical emergencies during sporting events. Having a plan is the single most important element of a safe football program, according to Bass.

“It’s about having a plan in place, knowing that the likelihood of injury is going to be well above 50% to at least one player,” Bass said. “Do I have the necessary equipment? Do we have splints? Does someone have a phone to call 911? Do we have an AED? Who will make sure gates are unlocked for the ambulance? Do I have the processes in place to deal with an emergency? If we don't have EMS on site, how is that going to change our approach to the need of care and transport? If I'm trying to do it on the fly when everybody's excited, that is not the ideal time to be discussing these things.”

Prioritize Professionals
“Whether it's basketball, football, baseball or any other sport, parents need to know, not just assume, that in the event medical care is needed, there is somebody there that's qualified to care for their child,” Bass said. “We realize there are differences, obviously, between the larger public schools with more established programs and smaller or private school programs, but it’s still full-contact tackle football, and it doesn't make any difference what level that it's played at. You still need to know who is there to care for your child if they are injured.”

In addition to physicians, board certified athletic trainers like Bass often serve as a team’s chief medical professional both on the sideline and in the locker room. Athletic trainers are allied health professionals who specialize in injury prevention, assessment, diagnosis, care and rehabilitation for athletes.

But not all schools have the resources to have a physician or athletic trainer on the sideline for every game. In this case, someone trained in basic CPR should be present, Dr. Guzman says.

“That's the most lifesaving part of this entire conversation,” Dr. Guzman said. “If a player goes down who's unresponsive for whatever reason, then someone can start and initiate CPR within seconds.”

As a Project ADAM partner, Cook Children’s is helping more that 530 schools in North Texas become “Heart Safe” by training school staff and coaches on CPR, how to use an automated external defibrillator (AED) and how to create an emergency plan.

What can parents do to help protect their athletes?

Stay Informed
Ask questions and communicate openly with coaching staff about their protocols in the event of an injury. With a concussion, for example, understand how your player will be evaluated on the sideline. Who and what will determine if they are or are not ready to go back into the game? Going back too soon, Dr. Guzman says, can lead to a traumatic brain injury.

“It’s really important to have that open door communication with the school and coaching staff, " Dr. Guzman said. “Make sure that all those things are in place to keep our kids safe. Don't just think that it's being taken care of. The state of Texas does a pretty good job of making sure that there are lots of protocols in place to keep kids safe, whether it's in the school or at these events, but I think we still need to be a part of that conversation as parents.”

Stay Alert
Kids don’t always speak up when they are hurt for fear of being benched or considered weak. Committed players will often try to tough it out, and that’s not always best for their health. Playing with an injury can lead to a more serious complication that ultimately increases an athlete's time away from the game.

“Parents have to watch for those subtle changes in their children,” Dr. Guzman said. “Whether they're walking a little differently or they're not picking up their backpack the same way.”

Bass says part of his role as an athletic trainer is to educate players about what their body is telling them, and to help them understand the process for getting them through that injury and back in the game.

“I tell them it’s how we deal with injury that ultimately determines the character of what kind of player we’re going to be,” Bass said. “So if we have something that is swollen, that is uncomfortable and just doesn't look the way it should, that's something we need to have evaluated.”

When an injury does occur, the John and Tracy Sellers Sports Complex at Cook Children’s Orthopedics and Sports Medicine Walsh Ranch, helps young athletes get back in the game with training and rehabilitation services. The Sellers Sports Complex also offers injury prevention programs and sport and position-specific training led by certified athletic trainers.

For more on this and health and safety tips for young athletes, click on the links below.

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With school back in session, many kids are once again suiting up for fall sports and hitting the field, track or court for competition. Doing so offers a child many benefits. Along with being an outlet for exercise and physical activity, playing sports gives kids an opportunity to develop meaningful friendships, practice resilience and learn the value of hard work and perseverance.

But, like with most activities, there are risks. Sustaining a concussion is one of them.

What is a concussion?

The Centers for Disease Control defines a concussion as “a type of traumatic brain injury caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth.” While sports, especially contact ones, carry an obvious risk of head injuries, a concussion can happen any time of year from any type of sport, recreational activity or play.

A 2018 report from the American Academy of Pediatrics evaluating three national injury databases estimated that 1.1 million to 1.9 million recreational and sports-related concussions occur every year in the United States in children 18 years of age or younger. When it comes to sports-related concussions for high schoolers, boys tackle football tops the incidence list with girls’ soccer coming in second, according to the report.

“A lot of concussions go unreported or undetected,” said Nicole Pitts, D.O., a sports medicine physician at Cook Children’s Pediatric Specialties in Prosper. “Usually 2 in 10 high school athletes who play contact sports, including soccer and lacrosse, get a concussion.”

Signs and symptoms

A concussion can sometimes be hard to spot. After all, it’s an internal injury. There are no visible cuts, bruises or breaks. Parents and coaches must rely on how a child feels and behaves to spot the signs and symptoms, which could have a delayed onset and last for days, weeks, months or more.

If your child takes a blow to the head, here are the signs and symptoms that they may have a concussion:

• Persistent headache or increasing head pressure
• Drowsiness or difficulty waking, characterized by grogginess, haziness, sluggishness or foggy feeling
• Dizziness and balance issues
• Blurry or double vision
• Weakness, numbness or reduced coordination
• Persistent vomiting, including nausea
• Slurred speech or slowed responses
• Convulsions or seizures
• Confusion, forgetfulness or difficulty recalling events before or after the injury
• Restlessness, agitation or heightened sensitivity to light and noise
• Behavioral or personality changes
• Loss of consciousness
• Asymmetrical pupil size (one pupil larger than the other)

What to do if you suspect your child has suffered a concussion

If you suspect your child has suffered a concussion, first and foremost, pull them from the game or activity.

“If they're in a game and you suspect they’ve had a concussion or had a blow to the head, or they're having any of those symptoms, even if you’re not sure, but suspect it, they need to be removed from the game immediately,” Dr. Pitts said. “That's the most important thing, and they should not be put back into play in that game or any activity on the same day at all.”

Have them evaluated by a professional, like a physician or athletic trainer, right away, especially if they lose consciousness, are confused and disoriented, are vomiting continuously and have trouble talking.

What's next

The clinical protocol for concussion treatment and rehab includes two strategies for evaluating an athlete’s recovery and readiness to get back in the game. The first 24 to 48 hours after a concussion should be a time of rest for the athlete, followed by a gradual and staged reentry to school and sports using the return-to-learn and the return-to-sports strategies. Athletes should remain in each stage for a minimum of 24 hours and should be able to complete the activities each stage allows with little to no exacerbation of concussion symptoms before moving to the next.

“We'll get them back into school first and once they're back in school and able to do all of their school activities and they're not having any symptoms, then we’ll start them on a return-to sports protocol,” said Carolyn Snow, MS, LAT, ATC, OTC, sports medicine coordinator at Cook Children’s Orthopedics and Sports Medicine. “We don't want to do any sports activities until they’re symptom-free.”

Dr. Pitts utilizes these clinical strategies with her concussion patients in Prosper. Cook Children’s Orthopedics and Sports Medicine concussion clinics at Walsh Ranch, Hurst and Mansfield also follow the return-to-learn and return-to-sports clinical protocols, in addition to utilization of a concussion testing tool called ImPACT to help determine a child’s readiness to return to activity. This computerized test measures memory, attention span, and visual and verbal problem-solving. Dr. Pitts is also certified to administer the ImPACT test.

Recognizing the signs and symptoms of concussion early on, and taking immediate action can help protect your young athlete’s mind from further or more serious injury. Getting the proper treatment and rehabilitation can minimize the long-term consequences from concussion and get them safely back in the game when the time is right. 

While it’s a fun time of year that many student-athletes look forward to, it's also time to freshen up on our knowledge about concussions so that we don’t put our kids at risk for severe long-term symptoms.

Mismanaged concussions can lead to severe headaches or a prolonged feeling of “fogginess” which can harm our athletes’ ability to learn. And it’s not just high school football players we need to be concerned about. Any athlete can suffer a concussion, including young children. 

So what should parents know? 

A recent study in Pediatrics looked at how long it took for athletes to recover following on a concussion depending upon rather they returned to play or were immediatly removed from the game. Those who went back in to play were nearly 9x as likely to suffer symptoms for more than 21 days. They also had worse scores on neurologic testing and had more severe symptoms than those that were removed.

Not removing an athlete from play is not the only mistake that parents and sports teams can make in regards to concussion management.

Here are 8 ways that parents and sports teams mismanage concussions that could be putting kids at risk:

1)They don’t recognize that a concussion has happened. If you notice a hard hit or hit to the head and see any of the following: headache, confusion, memory loss, nausea or vomiting or excessive fatigue, you have to assume it was a concussion until proven otherwise. If you notice any of those symptoms during an athletic event, even without an observed injury, you should still be very concerned. You don’t have to lose consciousness for it to be a concussion.

2)They trust the athlete to report their symptoms. Highly motivated student athletes know better than to report all of their symptoms because they know that it will get them removed from play. If you notice a hit and see the athlete acting different in any way, you must consider that a concussion despite the fact that they may say that they are “fine.”

3)They insist on a trip to the ER after a concussion. Most concussions can be handled by the trainer in conjunction with a doctor who has some advanced knowledge of concussion management. If the child is conscious and alert enough to talk with you, it can probably wait until the next day as long symptoms aren’t worsening or the athlete’s alertness isn’t decreasing. All that said, if you are worried about the athlete’s symptoms, go to the ER.

4)They insist on head imaging (CT or MRI) after a concussion. Head imaging is usually not necessary after a concussion assuming that symptoms are steadily improving over time. Remember that a head CT does involve radiation so minimizing its use is important.

5)They let the athlete return to play in the same game. As the study above mentions, this can be devastating to the child’s recovery. Prolonged and severe symptoms may be the result, leading to impairment for school work and a longer time to return to the sport.

6)They wake the child up overnight to check them after a concussion. This old teaching is one that still hangs on in the parent and trainer community despite a lack of evidence that it helps in any way. In fact, because rest is commonly what a concussed athlete needs, it could theoretically recovery worse. Would I walk in a few times at night and check on my son if he had a concussion? Sure, but I wouldn’t wake him up to give him a mental status exam.

7)They allow the student to participate in school activities too soon. After concussions, it’s not uncommon for students to need a slow return back to full activities, including school work. I don’t like this time period to be too long, but a couple days of half schoolwork might be necessary. You should work with a doctor who is able to fine-tune the play for your child.

8)They allow the athlete back into the sport too soon. An athlete that has had symptoms of concussion should not return to exercise until they are completely symptom free. If their main symptom is headache, they should be headache free before returning to light exercise, moderate exercise, sport specific practice and finally games. If symptoms return at any of those steps, they must step back to the previous level of activity until symptoms are gone. Again, working with a trainer and doctor who understand return to play protocols is critical to keeping your child safe.

Watching your student-athlete closely after a concussion, removing them from play the minute you notice symptoms and being cautious with their return to play will protect them from prolonged symptoms. It is critical that we remember that they are students first and that not protecting them after a concussion can result in prolonged impairment from school work.

Justin Smith, M.D., is a Cook Children's pediatrician in Lewisville . He attended University of Texas, Southwestern Medical School and did his pediatric training at Baylor College of Medicine. He joins Cook Children's after practicing in his hometown of Abilene for four years. He has a particular interest in development, behavior and care for children struggling with obesity. In his spare time, he enjoys playing with his 3 young children, exercising, reading and writing about parenting and pediatric health issues.

At Cook Children’s SPORTS Rehab, we’ve noticed a shift in what we see in our clinic. Over the past decade, the three major changes we’ve seen are the number of overuse injuries, the amount of early sports specialization and the way we treat concussions.

The first two issues I mentioned go hand-in-hand. It’s no coincidence that we are seeing more overuse injuries at the same time we are seeing early sports specialization. Overuse injuries come from repetitive micro-trauma to tendons, bones, and joints caused by repeating the same type of activity over and over.

If kids are playing the same sport all year around they are repeating the same movement patterns over and over again. Growing up in the 1980s and 1990s there wasn’t the opportunity to play year round sports like there is now. You may have had a favorite sport, but you had to wait for that season to roll around, and in the mean time you would play another sport if you wanted to stay active.

Now, if your favorite sport is baseball, you can find leagues to play in all year round, and the same is true for most other sports. As a result of this early specialization, we are seeing more and more overuse injuries in our young athletes.

In our baseball and softball players we are seeing more elbow and shoulder injuries, and the number one risk factor for overuse injuries of the shoulder and elbow is the volume of throws. If an athlete is playing baseball year round, the volume of throws is going to be significantly greater than an athlete that takes a break to play another sport.

A recent study showed that 15-19 year olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions (Tommy John) performed between 2007-2011.This means over half of these surgeries are being performed on patients who haven’t even finished their freshman year of college. While early specialization is a contributor to the uptick in these overuse injuries it is not the only factor. Things like poor mechanics, poor flexibility and inadequate strength all contribute to overuse injuries. As more and more kids participate in athletics there becomes more and more need for good conditioning and injury prevention programs. Increased sports participation is a great problem to have, because that means our kids are being active, but it also increases the need for our coaches, and we as parents, to be more aware of ways to keep our kids safe from these overuse injuries.

Treatment of concussion has been a popular topic in the news as of late, and this is an area that has changed significantly over the last decade and continues to evolve as we learn more about these injuries. Ten years ago we tried to grade concussions based on the severity. The concussions were graded 1-3 based on the patient’s symptoms and whether they lost consciousness. In some cases of Grade 1 concussions, the athlete was allowed to return to activities the same day as the injury.

We then switched to saying the athlete either has a concussion or they don’t, and all athletes that were deemed to have a concussion were disqualified from participation until cleared by a physician. In most cases we would shut these athletes down completely; limiting TV, school, phone time and interaction with other people in an attempt to let them get complete cognitive rest until their symptoms resolved. Then once symptoms resolved we would start a return to school and return to play protocol.

Now kids still have to be cleared by a physician, and they still have to follow a return to play protocol, but we have realized that completely isolating these kids while they recover and limiting their interaction with friends was doing more harm than good.

So after a brief period of brain rest (approximately three days), we start slowly integrating kids back into activities of daily life as tolerated. It is important to have a physician that deals with concussions involved in the patients return to activity so that they are getting the appropriate accommodations at school and home to allow for the appropriate amount of rest, but that will still allow enough activity to stimulate the patient enough to promote recovery and keep them from becoming isolated.

For more on the specifics of how treatments have changed for all of these areas, and for information on other changes in sports medicine, we would love for you to attend our annual Cook Children’s Sports Medicine Symposium July 21, 2016.

SPORTS Symposium

Education is the key to keeping our young female athletes in their sport vs. being on the sideline with an injury. To learn more Cook Children’s has an annualSPORTS Symposium to educate those who work with our athletes: Coaches, athletic trainers, physical therapists and school nurses.

Please join us on July 21, 2016, to learn more about the female athlete in the morning and what is sending athletes to the ER in the afternoon.

Click here to register and attend the event. Click here to register for the Web cast.

Early Bird Special Ends June 30, 2016

If you have paid attention to football over the last several years you know that there have been many rule changes geared toward preventing concussions.

Most of these rule changes have been spurred on by a huge law suit that was brought against the NFL by a large group of former players, in which the NFL will wind up having to pay out more than 1 billion dollars. The bottom line and what is portrayed in the movie is that there was research that brought into question the harmful effects of repetitive head trauma related to football. The NFL rather than looking into this and aiding this research in an effort to find out more, put its efforts into discrediting the research and trying to cover their own interests.

The research they were trying to discredit dealt with the autopsies done on the brains of former NFL players that displayed a condition called Chronic Traumatic Encephalopathy or CTE. CTE is a progressive degenerative disease found in people who have suffered repetitive brain trauma, including sub-concussive hits to the head that do not cause immediate symptoms.

Individuals with CTE may show early symptoms of dementia, such as memory loss, aggression, confusion, and depression. Just this past week Ken Stabler former Super Bowl winning quarter back for the Oakland Raiders who played 15 years in the NFL and who died in July was found to have stage 3 CTE.

While there is much more research that needs to be done to fully understand the potential long term effect of concussions and repetitive head trauma the current evidence can’t be ignored. One of the scariest things about concussions is how much we don’t know.

While the NFL is portrayed in a pretty bad light in the movie, in their defense I don’t think they reacted much differently to concussions than the majority of the population does. For the longest time I think a lot of people (myself included) had the attitude of “Oh it’s just a concussion.”

Working with concussion patients in clinic I have heard parents say, “I played football and got a few concussions I didn’t realize that it was a big deal.”

There are many athletes who might get a concussion, recover well and never have any other problems, but there are also patients who have an extremely difficult time recovering. We see patients take months to recover and report constant headaches, dizziness, blurred vision, difficulty concentrating in school, and mood swings.

We have seen patients whose parents report a complete change in their personality where they are much more angry and aggressive than they were before the injury. The scary thing is we don’t know how a person is going to react after a concussion, or how many concussions are too many, or if the repetitive sub-concussive trauma that they sustain is enough to cause problems later in life.

I played football when I was younger. I’m not coming out against playing football, but when I played you couldn’t start playing tackle until your eighth grade year which means 13-14 years old. We have to remember that elementary age through high school kids still have brains that are developing and we need to protect them.

The longer they play full contact football the more hits and more traumas they are exposed to, so I think we need to pay close attention to when we let our kids start playing tackle football. We also need to keep a close eye on how our kids recover if they do sustain a concussion. The longer and more difficult a patient’s recovery is the first time they have an injury, the more likely they will have a long, difficult recovery if they sustained another concussion.

Finally, how many concussions are too many? The answer is we don’t know for sure. What we do know is that concussions are mild traumatic brain injuries. We also know that CTE is a condition found in people who have suffered repetitive brain trauma. So how many concussions constitute “repetitive trauma?” That is a question we cannot answer for sure, but one that I think parents should think long and hard about before letting their kids back on the field.

SPORTS resources:

• The Cook Children's SPORTS program
• Football injury prevention
• What every parent should know about concussions
• There's no such thing as 'just' having your bell rung
• Top 10 questions parents have about sports injuries
• Injury Prevention Guide
• Strength training in children/adolescents
• Young athlete's injury prevention guide
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• Preventing children's sports injuries
• Pain that won't go away

It can be a hard thing for adults to deal with. Unfortunately, many children suffer the same pain. For some, it’s a genetic condition that’s been passed along to them. But for others, migraines are the result of injury. For 15-year-old Olivia Gillespie, her migraine problems began when she received her third concussion.

“It happened in cheerleading practice, I was kicked in the head,” says Gillespie. “I was fine. I didn’t think it was that big of a deal.”

Then months later, Gillespie was on a ski trip with her youth group when a headache came on and never went away.

“I just kept doing what I was doing and tried to not let it have an effect on me,” she said.

Gillespie tried to ignore the pain for two months before she said anything to anyone, but then the pain got worse.

“Olivia had an ongoing headache that would not fade. On a scale of one to 10, it was a consistent five," said Amelia Gillespie, the teen's mother. "It wasn't until her pain reached level seven that it really began to affect her.”

When Cynthia Keator, M.D., pediatric neurologist at Cook Children’s, first saw Olivia, she wanted to make sure her headaches could be treated without medication. Together, they worked on her sleep habits and diet. Dr. Keator also suggested supplements such as B2, and Omega 3, which has shown to help with headaches. In addition, Gillespie was referred to the Biofeedback Clinic at Cook Children’s.

“Biofeedback teaches patients how to control their pain by controlling their breathing, heart rate and body temperature,” says Dr. Keator.

Biofeedback specialist Nanny Christie, Ph.D., has been teaching the painless technique for decades.

“We place the child in a reclining chair and use pads to measure their body activity,” says Christie. “The equipment plugs into a laptop so the kids can see everything on the computer screen. If they tighten a muscle, a line goes up. If they relax, the line goes back down.”

Christie says teaching children to harness their breathing and muscle movement this way allows for real time learning. She says about 80 children are seen in her clinic each month. A typical visit is 45 minutes to one hour and each child is seen roughly four times.

While it wasn’t the end-all, be-all cure for Gillespie, it did help. She says she uses the technique to curb her head pain. If she feels a headache becoming worse, she can focus and calm her anxiousness which in turn can help the headache.

Also, ask your doctor about preventative medication. Your doctor may prescribe something prescription strength or a natural supplement to ease the pain.

Make sure you DON’T ask your child this question:

“How’s your headache?”

You may want to, but remember that asking about a headache is like scratching a mosquito bite. By asking, you’re reminding your child about their pain.

Last night, NBC 5 Investigates released an enlightening report looking at the rates of concussions in North Texas districts. This report showed a much higher rate with more than 2,500 concussions reported in just 41 districts.

There are still a lot of misconceptions about concussions, what they are and what they might mean to your student athlete.

Here are 5 concussion MYTHS:

1. It was just a “mild” concussion.

Concussions are brain injuries, period.

One might classify a concussion as mild if symptoms were brief and not severe. However, you cannot predict whose symptoms will be severe based on the way the child was injured or even the symptoms right after the injury.

Even seemingly minor trauma can cause headaches and other symptoms for weeks.

2. If the child/athlete didn’t lose consciousness, it wasn’t a concussion.

Symptoms of concussion vary from child to child but passing out or blacking out are not required to make the diagnosis. Basically if a child has a fall or other injury that results in any neurologic symptoms, they can be diagnosed with a concussion.

Some examples of concussion symptoms are headache, nausea/vomiting, vision changes or problems with concentration and memory. Some of these symptoms may take time to develop, so it’s possible to diagnose a concussion a few days after the injury.

3. Concussions are only a problem for football players.

Almost all sports can cause concussions, including the cheerleaders on the sideline of the football games. Some other sports that are known to have higher incidents are soccer, baseball and softball. Other common causes are kids riding bikes and falling off playground equipment.

4. All concussions need either an MRI or CT of their head.

Most concussions can be diagnosed based on telling your doctor the story of the injury and the related symptoms along with a physical exam. Imaging is not necessary because a CT or MRI will most likely be normal even in the midst of a severe concussion.

Also remember that a CT of the head does not come without risk. While we should perform them when necessary, we should make sure we are not using them in situations where they will not provide useful information.

5. Don’t let your child sleep after a concussion.

Treatment of concussions is evolving. If you suspect your child has sustained a concussion, you should immediately seek medical attention and advice from a doctor about how you should treat your child’s symptoms.

There have been some changes in the treatment of concussions. First, we no longer require that you keep someone with a concussion awake for a set period of time. In fact, after their evaluation, the doctor may recommend that you allow them to sleep in order to help their brain heal. Your doctor might also prescribe some time away from TVs and other screens, school or homework or other activities that might cause their brain to work harder.

Concussions are much more common than we previously thought. I believe that the UIL will make changes to better track the risk of concussions for our high school athletes, which will hopefully lead to better ways of evaluating and treating concussions. In the mean time, don’t buy these common concussion myths.

Richard Roberts, M.D., a neurosurgeon at Cook Children’s, wonders what it’s worth for your child to play sports with a reputation for head trauma.

“I think the fact that when the NFL players sued the league initially and won, the judge said the settlement (more than $700 million) wasn’t big enough,” Dr. Roberts said. “That says a lot about this growing issue more so than anything else.”

The issue discussed in the NFL cases has been CTE (chronic traumatic encephalopathy), a progressive, degenerative brain disease that has been found in some athletes with repetitive brain trauma.

Research is currently being done to study just how playing contact sports such as football mainly, but also soccer, can cause damage to an athlete’s head. But is it worth it for parents to wait for the results of this work.

“Amateur sports are different than professional sports because no one is feeding their family with the activity that they are doing,” Dr. Roberts said. We need to look beyond the short term and really understand what could happen in the long term. That potential for long term problems should be the primary thought, not the secondary thought.

“What is the actual incidence? We don’t know. But if it was your kid, how much would you be willing to risk? Even if it was 1 in 10, would you roll the dice on your own kid?”

Dr. Roberts has previously worked at Children’s Hospital in Philadelphia and Charity Hospital in New Orleans. While he saw concussions at the other hospitals, he’s never seen parents argue with him about concussions as he has seen at Cook Children’s.

“Part of what I’ve seen which is different here than other places is that I do get push back from parents who I think underestimate the severity of some of these injuries,” Dr. Roberts said. “Some of it is that they want their kids to play and I think some of it is the short term nature of some concussions.”

Children get concussions and they do well relatively quick, so opposed to having a broken arm which is in a cast or needing surgery and having stitches for three weeks, kids hurt their heads, they are knocked unconscious for five minutes, but then feel essentially better soon after. This apparent sign of improvement makes it difficult for some parents to grasp that their child may have a fairly significant brain injury.

“The more we understand concussions and the more we see people who have hurt their heads for various reasons, soldiers, professional athletes, anyone who has suffered a head injury, I think that we are seeing that in adulthood they are starting to have more cognitive issues,” Dr. Roberts said. “Now the science is not perfect yet. We can’t say to a football player you had three concussions and that’s why you have dementia. We can’t say to the soldier you were exposed to be a bomb blast and that’s why you have dementia because it could be multifactorial. It could be that you have the right genes to make you this way later on. But the percentage seems higher in people who have had traumatic brain injuries.”

Dr. Roberts says parents should be concerned after head injury one. He knows you have to let kids live their lives and be kids, but the brain wasn’t made to get beat up like happens sometimes in sports.

It’s not known for sure that after one concussion, people are more likely to get more, but Dr. Roberts’ suspicion is that it is likely the case.

And when does he have a serious heart-to-heart with the parents and the athlete?

“After two. We discuss no longer participating in the activities which could cause further injury because the likelihood of you having a head injury in your lifetime is still pretty high,” Dr. Robert said. “You are going to hit your head on a tree branch or you are going to fall off your bicycle or someone is going to run into you. You are going to be stepping out of the car and slip or walking across ice and fall down. My opinion after behavior has shown us that you are going to get injuries in a particular sport, you should probably not be playing in that sport because you are not able to protect your head.”

Dr. Roberts has seen strong reactions from both the parents and the kids after being told he or she should quit playing their respective sport. And it’s not just football as most people expect. It’s with the gymnast who has fallen off the bars and knocked herself out or the soccer player who has headed the ball and gotten knocked unconscious.

But football still remains king in Texas – in popularity and in concussions.

So what can be done about it?

Dr. Roberts is not sure there’s a good answer to that question. Building better equipment helps, but then armoring players probably makes them feel invincible and they hit harder. If you take away the facemasks or hard shell football helmets, he expects you will return to the old days – less concussions, but more skull fractures and in the process, immediate deaths on the playing field.

For now, Dr. Roberts wants parents to monitor their kids closely and to take the recommendations from their doctor closely. If they say it’s time to stop – stop!

“All the steps that sports are taking to make it safer are positive,” he said. “I think that everybody involved has to think less about return to play and more about long term health.”

About the source

Richard Roberts, M.D., is a neurosurgeon at Cook Children's. When a child with a neurological disorder requires surgery, the experts at Cook Children's Medical Center offer comprehensive care and state-of-the-art technology. With the help of such state-of-the-art equipment as the revolutionary intraoperative MRI (iMRI), our neurosurgeons are able to determine effectiveness of surgical procedures for cranial and spinal nerve disorders and tailor the treatment to each child's unique needs.

This is often said when someone is hit in the head during a sporting event. But this type of injury should never be taken lightly. A concussion can occur when a person has a trauma such as a blow to the head or the head being shaken. In fact, concussions can happen whether the person is actually “knocked out” (loses consciousness) or not.

Concussions are a common issue among school aged children and teenagers, especially if they are active in sports. In the United States alone, more than 300,000 concussions occur per year as a result of sports. An athlete who plays a contact sport, such as football, wrestling, basketball or soccer, is estimated to have a 19 percent chance of suffering a concussion in a single season. Other activities such as gymnastics, cheer, skateboarding, bicycling, or even jumping on the trampoline also come with an increased risk of concussion.

Can my child still get a concussion if he or she is wearing a helmet?

Yes. Although helmets do protect your child from a fracture of the skull or an injury that causes bleeding to the brain, they do not necessarily prevent concussions. It is possible to sustain a concussion while wearing a helmet because the helmet protects the bones of the head, but cannot stop the brain from making contact with the inside of the skull.

But what exactly is a concussion?

A concussion is a type of brain injury that interferes with the way the brain functions. It can cause symptoms such as:

• Headaches
• Nausea and vomiting
• Vision changes
• Irritability
• Difficulty concentrating
• Memory problems
• Balance issues
• Sleep disturbances

The majority of concussions (80-90 percent) resolve within 7-10 days, but may take longer for children and adolescents. Sometimes, the symptoms of a concussion will linger or worsen. If symptoms become persistent, your child may require further treatment to help symptoms resolve so they are able to return to attending school and participating in normal activities. Even a child with a “mild” concussion should be evaluated by a physician. A doctor will be able to decide if any tests are needed to check for more serious injuries. He or she will also check your child’s symptoms to find out the severity of the concussion, and determine whether referrals to other healthcare providers, such as a physical therapist, are required.

As a parent, what do I need to know to help my child get back on the playing field after a concussion?

Patience is key when it comes to safely returning to sport following a concussion. Every young athlete is eager to get back to sports or activities as soon as possible. It is up to the parents to make sure that this process is not rushed and happens in a safe way. More and more research studies are proving that the effects of concussions can compound and have long-term effects if another concussion occurs before adequate time for recovery is allowed. If an athlete or child returns too soon, he or she may be susceptible to negative effects of post-concussion syndrome such as depression, memory loss, fatigue, chronic headaches or pain. Parents should be diligent with following up with healthcare providers to get appropriate treatment prior to returning to sports.

How can a physical therapist help an athlete return to sport after a concussion?

Physical therapists will assess the need for treatment of any musculoskeletal injuries that occurred at the time of concussion. If your child has pain in the muscles or joints of the neck or spine as a result of injury, a physical therapist can help decrease this pain with hands on techniques or exercises. An injury to the brain can affect the brain’s ability to tolerate physical activity, movement, and balance. Sometimes these symptoms interfere not only with an athlete returning to his or her sport, but also with every day activities such as attending school, reading a book, or playing video games. A physical therapist will also assess the athlete’s tolerance for activity, function of the vestibular system (a part of the inner ear), and balance.

A physical therapist has the ability to monitor a patient’s symptoms while safely progressing from light aerobic activity, to sport-specific drills and eventually to non-contact drills. This allows the athlete to return to full practice and eventually to his or her sport. The vestibular system is a part of the inner ear that sends signals to the brain regarding a person’s movements and position in space. Additionally, the vestibular system is closely associated with an athlete’s ability to maintain balance. Balance can be affected when a child suffers a concussion, and can require rehabilitation from a physical therapist. Physical therapists can use specific exercises designed to strengthen the vestibular system and improve balance to prepare your child to safely return to sport or activity.

So what’s the bottom line when it comes to concussions?

1.Head injuries, or “getting your bell rung”, should not be taken lightly.

2.Helmets protect the skull, but do not always prevent concussions.

3.It is important that a physician evaluate your child after an injury to the head.

4.Parents and athletes must be patient in order to safely return to activities in order to allow concussions to fully heal.

5. Physical therapists can treat patients who have had a concussion to help with musculoskeletal or vestibular system issues, tolerance for physical activity, and balance training to help safely return to sport.

For more information:

• What every parent needs to know about concussions
• Concussion management and update
• Football injury prevention
• ​Soccer injury prevention
• Hockey injury prevention
• Gymnastic injury prevention
• ​SPORTS resources
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Top 10 questions parents have about sports injuries

About the author

Jessie L. Diebold, PT, DPT, OCS, is a SPORTS physical therapist at Cook Children’s. Cook Children’s SPORTS Rehab is a leader in the community in sports injury. Additional information and helpful tips can be found on the Cook Children’s SPORTS Rehab website. Cook Children’s SPORTS Rehab is a leader in the community in sports injury prevention.

After a child sustains a concussion, he or she should be removed from the game or practice in order to allow the brain to rest. While the importance of rest following a concussion has been scientifically validated, the definition of "rest" has not been well-established. As such, an individualized approach to concussion management is preferred. While limiting physical activity is often the first area considered when a child is instructed to rest, limiting stress in other areas of life can be equally important. In addition to physical rest, cognitive and emotional rest is also important following a concussion.

Although an extreme approach to cognitive rest is sometimes recommended, studies suggest that a more moderate approach results in better long-term outcomes. In fact, scientific evidence documenting the benefits of cognitive rest is limited. Nevertheless, limiting cognitive exertion can decrease the frequency or intensity of other symptoms, such as headache.

School is the most cognitively demanding activity for most student athletes, and their baseline level of academic functioning should be considered when creating a treatment plan. Students with more severe symptoms may benefit from staying home from school for 1 to 2 days.

However, because symptoms typically resolve within a few days, formal homebound education services are generally unnecessary because the amount of instruction provided is minimal (e.g., typically only about 4 hours per week). Furthermore, homebound school services are typically reserved for students expected to miss school for an entire month.

Immediately returning to school may be a better option for some students with mild symptoms as well as students who are likely to become severely distressed if they miss a day of school. In addition, when children are told to maintain complete cognitive rest (e.g., sit quietly in a dark room with no electronics), they may become overly focused on their symptoms and consequences of rest (e.g., having to make up multiple school assignments later).

It is also important to understand the role of electronics and technology in the lives of children, especially adolescents. While using a computer or texting on a telephone may trigger headaches, completely prohibiting a teenager from engaging in these activities can result in social isolation and contribute to emotional distress. Depending upon the assignment, prohibiting all use of electronics can result in a student being unable to complete homework requiring use of a computer.

When compared to other areas, less attention is typically given to importance of emotional rest. Particularly for teenagers, social and emotional situations can be a big concern. Limiting a child's exposure to volatile emotional situations (e.g., pressure from friends and coaches to return to play, arguments between parents) is important. In addition, peers and teachers often have a variety of reactions to a child's concussion.

For example, while most people will likely respond with understanding and support. Others, however, may discount the significance of the child’s symptoms and doubt whether the symptoms are "real" because the child does not look "sick."

When the validity of symptoms is questioned, a child will sometimes unconsciously exhibit persisting or worsening difficulties. An athlete may also feel pressure from peers, teachers, or parents to return to play before they are ready, which can lead to emotional distress as well as the appearance of persisting or worsening of cognitive symptoms.

A concussion often results in increased fatigue, particularly in the first few hours after the injury. Indeed, some scientific evidence shows that physical rest during the first 24 to 48 hours may result in an overall faster recovery. In addition, because other studies have demonstrated that a concussion sustained within a week of a prior concussion can result a longer duration of symptoms, avoiding high-risk activities (e.g., returning to play) in the days following a concussion may be best.

However, studies have also shown that extreme physical rest for more than 3 days can worsen symptoms and lead to deconditioning. Most children and adolescents who sustain a concussion will stop experiencing severe symptoms within hours to days and will completely recover within a few days to a couple of weeks.

Regardless of when a student returns to school, it is important that the school nurse and all teachers be informed that the student has sustained a concussion. Following a concussion, students may exhibit inattention, distractibility, slow thinking, and confusion as well headaches, vision difficulties, and fatigue.

Some temporary accommodations can include preferential seating in the classroom (e.g., at the front of the room and away from distractions), testing in a separate room, extra time to complete tests and assignments, shortened assignments, copies of teacher notes prior to lectures, note-taking services, rest breaks during the school day, and permission to eat lunch in a quiet environment.

Considering the typically rapid recovery following a concussion, a formal accommodations plan at school is usually unnecessary because, by the time a plan has been finalized, the student is no longer symptomatic.

If, however, a child is slower to recover, a more thorough medical evaluation may be necessary to further investigate and treat physical dysfunction (e.g., headaches, dizziness). In addition, a neuropsychological evaluation can be helpful in evaluating the specific areas of cognitive difficulty and severity of the deficits as well as provide guidance regarding the need for a more formal academic plan.

About the author

Carla Hearl Morton, Ph.D., is a pediatric neuropsychologist at Cook Children's. She is a licensed psychologist with expertise in how learning and behavior are connected to the development of a child's brain structures and systems. At Cook Children's, neuropsychologists work closely with a team of neurologists andneurosurgeons to provide the best treatments and interventions that meet the individual needs of each child.

Primary headaches are the result of problems with pain sensitive structures in your head. These include migraines, tension headaches, chronic daily headaches, cough headaches and exercise headaches.

Secondary headaches usually point to an underlying condition activating the pain sensitive nerves in the head. These include sinus pressure, concussion, dehydration, ear infection, flu, tooth pain, etc. More serious causes of headaches can occur, for which you would need to see a doctor immediately.

Physical therapy is well suited to help patients with headaches. Most primary headaches can be related to or made worse by muscular tightness in the neck, base of skull, and head. This tightness can be due to trauma, joint stiffness, joint instability, poor posture or overuse. Physical therapists can address this muscular tightness in several ways. We work on increasing the flexibility of the muscles involved, improve the strength of the musculature in the area, and mobilize stiff joint segments. We also address the child’s posture and stability of the area by retraining the musculature to work in symphony with each other to achieve good posture and stability of the neck and shoulders during static and dynamic activities.

Here are four ways for kids to improve their headaches:

1. Be aware of your posture. How are you sitting when at school? Where do you do your homework or read? Is it on your bed, or couch, or on a desk? Try to improve your posture by sitting up straight, preferably in a chair that offers low back support and keeps you upright. Make sure that the computer or books are close enough that you can read easily without looking down or sticking your chin forward.
2. Take mini breaks throughout the day. A good rule of thumb is a 2 two- minute break for every 30 minutes. During this time, get up walk around your space, stretch.
3. Stretch. Your muscles tend to tighten down to match the movement they are allowed during the day. If they don’t move much, they will begin to tighten. Neck and shoulder stretches are important to loosen the muscles you use to hold your head up and use your arms during the day. The stretches should be held for at least 30 seconds for better results.
4. Build strength in the muscles of the neck and shoulders. The stronger your muscles are, the better they can handle the stresses of the day. Exercises could include chin tucks, shoulder shrugs, lat pulls, rowing, pushups and tricep dips.

If you have any questions, please feel free to contact your pediatrician.

About the author

Bruce Morgan, PT, is a SPORTS physical therapist at Cook Children's. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind.

He’s not hurt and had a presumably bright future in the NFL.

Why did he retire?

In light of the recent focus on repetitive trauma, concussion and brain injury, he decided that it was in his best interest to stop playing football.

Consider it this way: After years of playing football, starting a very young age, succeeding in high school and later at the University of Wisconsin, he reached the pinnacle of his sport and decided it was better to walk away than to keep playing. Granted, he’s only one player and many, many more will continue to make the decision to go back to training camp in July.

Most football players will never reach that point where they’ll have to decide if the NFL is right for them. I played junior high football, but didn’t move on to high school. I like to tell myself that I was making sure I was protected from injury for tennis season (truth was, I was probably a little scared of being small and getting hit by bigger high school kids. Sorry for lying, Coach West).

If you look at the research,  it seems like cumulative trauma is the issue. The older and bigger you get and the longer you play, the number and the force of the traumas increase. The rules are changing in an attempt to make the sport safer. But, I’m sure many of you read this and worry about your young football players.

My sons haven’t asked to play football yet. At 5 and 3, I think the level of risk for concussion is higher when I pick them up and throw them as high as I can in the air barely grabbing them before they crash into the ground. But living in the middle of Texas, football countr,y and having an older son built like a perfect tight end and having little brother with a canon for an arm, I am sure that is a conversation we will have some day.

I wonder if someday we’ll look back on the days when football was played and think, “I can’t believe that they used to do that to themselves.” Or, will the sport look so different that we will barely recognize it?

What about you? Do you have concerns about your sons playing football?