Sports Medicine: Just the Facts

• The risk of sustaining a concussion in football is four
  (Gerberuch et al, 1983) to six (Zemper, 1994) times
  greater for the player who has sustained a previous
  concussion. It can occur with direct head trauma in
  collisions or falls, or may occur without a direct blow
  to the head when sufficient force is applied to the
  brain, as in a whiplash injury (Lindberg and Freytag,
  1970).


• While earlier estimates of concussion in football were
  as high as 20% (Gerberuch et al, 1983), current esti-
  mates place the incidence at 5–10%.


• It must be realized that universal agreement on the
  definition and grading of concussion does not exist.
  This renders the evaluation of epidemiological data
  extremely difficult.
  •Tables 40-3 and 40-4 are the most widely cited guide-
  lines.
  •Table 40-3 guidelines are at odds with subsequent
  studies of Lovell et al (2003), Collins et al (2002), and
  Erlanger et al (2002) that found on the field memory
  problems/amnesia best correlated with the number
  and severity of postconcussion symptoms and post-
  concussion neuropsyche scores at 48 h. Brief loss of
  consciousness(LOC) did not.


• In the clinical evaluation of concussion—postconcus-
  sion signs and symptoms (PCSS) checklist (see
  below) should be employed, and all of the signs and
  symptoms noted in Table 40-5 should be sought.
  •Today it is recognized that after concussion the ability
  to process information may be reduced (Gronwell and
  Wrightson, 1974), and the functional impairment may
  be greater with repeated concussions (Gronwell and
  Wrightson, 1974; Symonds, 1962).


• The late effects of repeated head trauma of concussive
  or even subconcussive force leads to anatomical pat-
  terns of chronic brain injury with correlating signs
  and symptoms.

POSTCONCUSSION SYMPTOMS

•A second late effect of concussion is the postconcus-

sion syndrome. This syndrome consisting of headache

(especially with exertion), dizziness, fatigue, irritabil-

ity, and especially impaired memory and concentra-

tion has been reported in football players, but its true

incidence is not known.

• The persistence of these symptoms reflects altered
  neurotransmitter function and usually correlates with
  the duration of posttraumatic amnesia (Guthkelch,
  1980).


• When these symptoms persist, the athlete should be
  evaluated with a computed tomography (CT) scan and
  neuropsychiatric tests. Return to competition should

240 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE

TABLE 40-5 Post Concussion Signs/Symptoms Checklist

Bell rung Nausea
Depression Nervousness
Dinged Numbness/tingling
Dizziness Poor balance
Drowsiness Poor concentration
Excessive sleep Ringing in the ears
Fatigue Sadness
Feeling “in a fog” Sensitivity to light
Feeling “slowed down” Sensitivity to noise
Headache Trouble falling asleep
Irritability Vacant stare/glassy eyed
Loss of consciousness Vomiting
Memory problems

TABLE 40-2 Sports without Helmets

Men’s soccer 0.25
Women’s soccer 0.24
Field hockey 0.20
Wrestling 0.20

SOURCE: (Dick, 1994)
Rate of concussions per 1000 athlete exposures.

TABLE 40-3 AAN Practice Parameter (Kelly
and Rosenberg) Grading System for Concussion

Grade 1 Transient confusion; no loss of consciousness; concussion
symptoms or mental status abnormalities on examination
resolve in less than 15 min
Grade 2 Transient confusion; no loss of consciousness; concussion
symptoms or mental status abnormalities on examination
last more than 15 min
Grade 3 Any loss of consciousness, either brief (seconds) or
prolonged (minutes)

TABLE 40-4 Data Driven Cantu Grading System
for Concussion
Grade 1 (Mild) No LOC, PTA, PCSS <30 min
Grade 2 (Moderate) LOC <1 minute or PTA >30 min <24 h
PCSS >30 min <7 days
Grade 3 (Severe) LOC ≥1 min or PTA ≥24 h, PCSS >7 days

SOURCE: Cantu RC: Post traumatic (retrograde/anterograde) amnesia;
pathophysiology and implications in grading and safe return to play.
J Athl Train36(3):244–248, 2001.
ABBREVIATIONS: LOC =Loss of consciousness; PTA =post-traumatic
amnesia; PCSS =postconcussive signs/symptoms other than amnesia.

TABLE 40-1 Sports with Helmets

Ice hockey 0.27
Football 0.25
Men’s lacrosse 0.19
Woman’s softball 0.11

SOURCE: (Dick, 1994)
Rate of concussions per 1000 athlete exposures.