Knocked Out

When does a hit become one hit too many? New concussion research shows that head injuries sustained by young athletes have more serious long-term consequences than once thought.

The first concussion occurred eight years ago, when Matt Hovila was a fourth grader playing in a youth football league in Bloomington.

The 10-year-old running back was dashing down the field with the ball (and his helmet strapped firmly in place) when “a guy picked me up and slammed me down,” he recalls. “I landed on the back of my head.”

Dizzy and confused, Matt sat out the rest of the game. Afterward, his parents took him to a hospital, where he had a brain scan. His skull looked undamaged, and the doctors gave Matt the OK to return to football.

The second concussion came two weeks later, when he landed on the back of his head after being tackled. This time, he experienced headaches. And this time, the doctors and his parents told him he couldn’t play football anymore. It was an emotional blow to an athletic kid who loved the game and was good at it. But Matt accepted the decision—and switched to basketball.

The third concussion occurred two years later, while he was playing in a school traveling league. He took a charge from another player and fell backward, hitting his head on the hardwood floor. He lay unconscious for a few seconds and needed help walking back to the bench. “And I had a pretty bad headache,” he recalls.

After a few weeks’ rest, Matt returned to play. Then, late in the season, while jumping for a ball, he banged heads with an opposing player. “It wasn’t a hard hit, but it was so close to the first one,” he says.

Matt and his parents aren’t sure if that was a concussion, but, looking back, they see it as a turning point in his young life. “It’s when all my school problems started,” Matt says. “Before, I was an A student who could do anything in school. But then I became a whole different person.”

He found it difficult to focus and pay attention. He fatigued easily, and was frequently irritable. Reading became a frustrating challenge—until doctors discovered that Matt’s latest concussion had altered his vision. But even a new eyeglass prescription didn’t improve things at school. In fact, Matt’s symptoms, including severe headaches, got so bad he had to be home-schooled for three months in seventh grade.

“I went from taking advanced-placement classes to special ed,” he says.

Matt’s story is not uncommon in Minnesota. Each year, roughly 1,000 children and teenagers ages 5 to 18 go to the hospital for sports-related concussions, according to the Minnesota Department of Health. But that number is probably 10 times higher, say officials, because most concussions go unrecognized by kids and their families.

Precise statistics about Minnesota’s youth-related sports concussions are hard to come by because there’s no good data-tracking system in place. National research suggests, however, that such concussions have been steadily rising—and in many sports. One recent study, for example, found that traumatic brain injuries among kids playing basketball climbed 70 percent between 1997 and 2007.

This fall, Minnesota may see a slight spike in the number of concussions reported. A new law signed by Governor Mark Dayton in May will send more youngsters to emergency rooms for evaluation after sports mishaps.

Or, instead, counts could go down, now that USA Hockey, the group that governs amateur hockey, has implemented new body-checking rules explicitly designed to minimize head injuries.

But however the numbers turn out, one thing is clear: kids are playing sports with a whole different mindset.


Until recently, coaches, trainers, parents, and even some medical professionals tended to dismiss most concussions as minor bumps to the head. If a kid received a brain-rattling hit while playing, he or she was simply told to “walk it off” and get back in the game.

Such advice is dangerous—and not only because failure to get quick treatment, even for a concussion that seems relatively minor, can be life threatening. Returning kids to play too soon also leaves them more vulnerable to more extensive injuries.

“It’s easier to get serious brain damage or death with a second impact, even if it is lighter than the first one,” says David King, president of the Brain Injury Association of Minnesota. Kids are particularly susceptible to second-impact damage, he adds, and their brains take longer to heal.

And girls are just as susceptible as boys. Laura Nickel suffered back-to-back concussions in 2009 while playing high-school soccer in Byron. “I had a lot of dizziness, vertigo, and trouble concentrating,” she says. “I also had a little bit of a stutter.” Now a student at Bethel University, Nickel still takes medicine for headaches and finds she can’t sit in front of the computer for very long. “Whenever anybody says they hit their head, I tell them to take it seriously,” she says. “I shouldn’t have kept playing.”

That message—that all bangs to the head are potentially serious medical events—is finally getting through the rest of our thick skulls. One major reason: within the past decade neuroscientists have nailed down a clearer picture of what goes on in the brain during a concussion. And it isn’t pretty. The brain, which floats in a pool of cerebral spinal fluid, first slams into the interior of the skull at the point of impact and then ricochets into the opposite side of the skull.

But that’s not all. The force of all that movement shears nerve cells, triggering a harmful cascade of brain chemicals that leads to even more damage. Those secondary injuries, which may not develop for several hours or even days, are what cause long-term effects, such as cognitive decline and emotional changes.

Brain-imaging technologies offer minimal help with diagnosing a concussion. They can show damage to the skull or bleeding on the brain, but not subtle nerve damage. That’s why so many young athletes, like Matt Hovila, have been sent back onto the playing field: Their brain scans looked “clean.”

Neuroscientists laid the groundwork for the concussions discussion. But the public didn’t really grasp the story until they started reading tragic tales of retired professional athletes whose brains—and lives—had deteriorated due to repeated on-field head injuries. First came the reports of horrific signs of degeneration in the autopsied brains of former pro athletes with strong concussion histories who had later committed suicide or who had suffered from dementia. Other troubling studies followed, including one in 2010 that pointed to sports-related brain trauma as a possible risk factor for the neurodegenerative brain disease amyotrophic lateral sclerosis, or ALS. One of the examined brains was that of Wally Hilgenberg, a Minnesota Vikings linebacker in the 1970s who died of ALS in 2008.

Suddenly pro athletes were taking themselves out of play for long stretches of time to let their brains heal—players like Minnesota Twins first baseman Justin Morneau and Minnesota Wild defenseman Nick Schultz, who both sat out the end of their seasons last year. Minnesota sports fans were overwhelmingly supportive—a reaction that suggests former macho attitudes toward sports injuries may be shifting.

One of the biggest shifts has occurred among youth coaches. “Coaches have become much more enlightened about the seriousness of concussions,” says King. “They’re becoming acutely aware that the idea that ‘it’s all part of the game’ is not true.”

Dave Ziebarth, head football coach at St. Thomas Academy in Mendota Heights, is one of those enlightened coaches. He’s a stickler about keeping players with suspected head injuries off the field until they receive medical clearance. Any coach who doesn’t do that today would be “a complete idiot,” he says.

Ziebarth, whose teams typically experience five to seven concussions a season, requires players to take an online baseline test each fall. Any player with a suspected concussion must retake the test. “They have to get back to the baseline they started with before they play again,” says Ziebarth.

One of Ziebarth’s challenges is getting injured players to admit their symptoms— kids dread not being able to play. “But that attitude is turning around,” says Ziebarth. “They’re starting to understand that if the injury is caught early, they’ll be out for a shorter time.”

Parents are beginning to understand the repercussions, too. Only once did a father give Ziebarth trouble for a benching decision. “He argued with me for a little bit, but then he settled down,” recalls Ziebarth. “He later said he had been emotional because he knew how much his son wanted to play. But then he realized it was in his son’s interest to wait until he had healed.”


Major changes in youth sports are on the way. The Minnesota legislature, in a rare display of bipartisanship, enacted a law last spring that requires youth coaches and officials to complete a government-designed online concussion-focused training course. The law also requires young athletes to be removed from play or practice immediately at the first sign of a concussion. They can’t return until getting an all-clear from a qualified healthcare professional.

State Senator Terri Bonoff was one of the law’s most vocal supporters, and with good reason. Both her sons experienced career-ending concussions in high school, one while defending home plate from an aggressive base runner and the other after being tackled by four linemen. “I understand just how serious concussions are,” says Bonoff, “and what they do to the brain.”

Hockey parents will notice major changes this season. In June, USA Hockey banned body-checking during games played at the boys’ peewee level (ages 11-12). (Body checking isn’t permitted in girls’ hockey.) Furthermore, gratuitous hits at all levels are going to be more strictly enforced, says Michael Stuart, co-director of the Mayo Clinic’s Sports Medicine Center and chief medical officer for USA Hockey.

Minnesota Hockey’s board of directors vigorously opposed the rule change, claiming it would result in more injuries because boys wouldn’t be prepared for body-checking upon leaving the peewee level. Canadian research says otherwise, notes Stuart.

“The opposition felt we were violating the sanctity of the game,” he adds. “But actually, we’re not. We’re making the game better.”

“Everybody thinks [body-checking] is OK until it’s their child or grandchild who misses eight weeks of school because they’re seriously injured with a brain injury,” says Hal Tearse, coach-in-chief of Minnesota Hockey, who supports the change.

In ninth grade, Matt Hovila nervously returned to the basketball court. Three injury-free years later, he was voted captain of his Bloomington Jefferson High School Jaguars.

Then, during the final minutes of a game last January, he took a sharp blow to the base of his skull. “It was pretty bad pain,” Matt recalls, “but I didn’t think it was a concussion.”

About an hour later came the all-too-familiar symptoms: headache and dizziness. His parents rushed him to the hospital, where doctors confirmed that he had indeed sustained a concussion.

“I was done after that,” Matt says.

Now 18, Matt will attend Minnesota State University at Mankato State this fall—if his health lets him.

But just because he can’t play sports anymore doesn’t mean he’s completely sidelined. Last spring, he volunteered as a speaker for the Brain Injury Association of Minnesota. “I tell people not to go back too early,” he says. “Make sure you’re symptom-free.”

Susan Perry is a Minneapolis journalist who frequently writes about health and medicine.

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