Sports Medicine: Just the Facts

CHAPTER 83 • FOOTBALL 495

such as reciting the months of the year in reverse order.

Athletes should always be assessed for the presence of

antegrade (since the time of injury) or retrograde (prior

to the injury) amnesia.

• Normal testing as above, absence of headache, and
  return to baseline neurocognitive and emotional states
  are the key features to the determination of suitability
  to return to play.


• Previously published concussion guidelines and grad-
  ing systems (e.g., Cantu, Colorado Medical Society,
  American Academy of Neurology) have found a poor
  correlation between the degree of impairment in neu-
  ropsychologic testing and the anticipated time to
  return to play from a concussive injury. For example,
  loss of consciousness had previously dictated a
  lengthy period of disqualification. It is now generally
  accepted that briefloss of consciousness (<15 s), in
  the absence of other classic features of concussion,
  residual neurologic dysfunction as outlined above, or
  cervical spine injury does not necessarily preclude
  return to play even in the same contest. Any athlete
  suffering a longer period of loss of consciousness
  should be held from participation and considered for
  urgent neurosurgical evaluation.


• Emphasis is now being placed on the description of
  the concussion’s characteristics (presence and dura-
  tion of antegrade or retrograde amnesia, headache,
  vomiting, vision change, persisting confusion or dis-
  orientation, sleep disturbance) as opposed to a spe-
  cific grade, which had previously dictated a rigid
  course of management. Concussions are sufficiently
  heterogeneous that they require flexibility in their
  diagnosis and management, particularly with respect
  to return to competitive athletics.

COMPLICATIONS

• The most feared complication of concussion is the
  “second impact syndrome,” a potentially fatal cascade
  of cerebral hemorrhage and edema resulting from a
  second concussive blow following incomplete resolu-
  tion of a first concussive event. Although exceedingly
  rare, the chance of second impact syndrome should
  absolutely dictate disqualification until the concussed
  athlete has completely recovered from their initial
  injury.


• Neuropsychologic testing has demonstrated the pres-
  ence of lower cognitive function in collegiate football
  players with a history of multiple concussions (Collins
  et al, 1999). Similarly, it is well shown that prior NFL
  football players have a higher rate of cognitive dys-
  function than the general population. In addition, sev-
  eral notable players retired from the NFL as a result of
  increasing severity and frequency of concussion and a
  concern about long-term cognitive loss.
  
  
  • Studies have linked the presence of apolipoprotein E
    (apoE4) genotype and risk for cognitive impairment
    with head injury. Older professional football players
    who possessed the apoE4 allele scored lower on cogni-
    tive tests than did players without this allele or less
    experienced players of any genotype (Kutner et al,
    2000). The resultant cognitive status of such athletes
    with repeated head trauma appears to be influenced by
    this genetic predisposition as well as age and cumulative
    exposure to contact. Although its utilization as a screen-
    ing tool is still under study, apoE4 and similar genetic
    markers may become a practical means of determining
    an athlete’s relative risk for permanent neurocognitive
    loss in association with head injury in sport.
  
  
  
  

HEADACHE

•Football-related headache is common with 85% of

sampled high school and college football players

reporting headache as a result of hitting (Sallis and

Jones, 2000). Twenty-one percent reported headache

in their previous game; only 19% of those individuals

reported the headache to the sports medicine team and

only 6% were removed from play.

•Defensive backs (25%), defensive linemen (19%), and

offensive linemen (18%) were most likely to have

headache related to hitting. Given the high rate of

headache and the low rate of serious complications

(cerebral hemorrhage, second impact syndrome), the

presence of headache, unless persistent or accompa-

nied by other symptoms, does not mandate disqualifi-

cation from competition.

HEAT ILLNESS

• Heat-related illness in football is common as a result
  of practice and play in warm weather months and
  extensive body coverage with heavy padding and
  helmets, which intrinsically impair heat dissipation.


• Heat illness may manifest as a broad spectrum of con-
  ditions including heat cramps, heat syncope, heat
  exhaustion, and potentially lethal heat stroke.


• Heat cramps, syncope, and exhaustion are character-
  ized by heat-associated physiologic changes that do
  not result in significant elevations in core body tem-
  perature or in central nervous system dysfunction.
  Heat cramps and syncope may be treated safely with
  aggressive oral hydration, external cooling measures,
  electrolyte supplementation, and rest.


• Heat exhaustion is heralded by complaints of dizziness,
  headache, nausea and vomiting, and generalized weak-
  ness and malaise. Core body temperature (measured