Concussions and Head Injuries
Josh Krassen, DO
Proper diagnosis and management of head injuries are essential skills for any sports medicine practitioner. Head injuries (as well as neck and cervical spine injuries, discussed in chapter 5) have a high incidence of critical injury and death and must always be treated seriously. Athletes and those who work with them must be educated on head injuries, knowledgeable about the proper safety equipment and rules and regulations that can prevent such injuries, and aware of how to assess an athlete’s risk for returning to play. Determining when an athlete who has sustained a head injury can return to play should be based on a careful medical evaluation of the athlete. Often the decision is based on limited observation of an athlete and a brief sideline evaluation. Frequently, pressure from a player or coach complicates or even influences a decision. Obviously, in the case of a head injury, the return-to-play decision must always be in the best interest of the athlete.
This chapter looks at several head injuries in terms of their causes, identification, and treatment. Included are injuries to the ear, jaw, nose, and eye as well as concussions and other related head injuries.
Subdural and Epidural Hematoma
Nasal and Mandible Fractures
An impact to the head, neck, or elsewhere to the body causing an acceleration–deceleration force to the head may result in a concussion (note that a cervical spine injury should also be suspected with such an injury; see chapter 5).
Identification and Prevention
A concussion is a traumatically induced alteration in mental status, such as confusion or amnesia, that may or may not involve a loss of consciousness (Kelly et al. 1991). It is based on functional, not structural, pathology, because imaging is often normal and not diagnostic of injury. There are 1.6 to 3.8 million sports and recreational concussions per year, and 135,000 are seen in the emergency room (Langlois JA et al. 2006). This injury most commonly occurs in American football during tackling or blocking but also occurs in other sports, such as in soccer when a player heads the ball or in ice hockey (more prevalent in women). There is good evidence that helmet use in skiing and snowboarding reduces head injuries. Limiting body checking in youth ice hockey and contact in youth football has also been shown to reduce head injuries. Teaching proper tackling techniques in football and avoidance of heading duels in soccer helps to reduce the risk of concussions. Evidence on use of mouth guards is inconsistent. Athletes with a history of previous concussions are more likely to have recurrent concussions (Guskiewicz et al. 2003).
It is important to have standard policies and protocols in place for education of players, referees, coaching staff, and parents of youth to help identify and understand the signs and symptoms of concussions. Everyone should have an understanding of its clinical features, assessment techniques, and principles for safe return to play. Concussions may involve clinical symptoms, physical signs, cognitive impairment, neurobehavioral features, and sleep–wake disturbances. Athletes can present with headaches, feelings of fogginess and drowsiness, forgetfulness, or irritability, or be emotionally unstable. Gait unsteadiness and slow reaction times are often noted. If any of these symptoms are observed, the athlete should be safely removed from practice or play.
Assessment of Injury
Rapid onset of short-lived neurological impairment that resolves spontaneously is typically seen with concussions. In some cases, symptoms may evolve over minutes to hours. These symptoms reflect a functional disturbance of the brain, not a structural injury. Primary assessment should include maintaining airway, breathing, and circulation, and stabilization of the cervical spine in case of fracture. Blood pressure, heart rate, and pupil reactivity should be assessed. More common symptoms include headache (83 percent), dizziness (65 percent), and confusion (57 percent) (Delaney et al. 2002). Neurological exams should be performed by a medical professional every five minutes until the athlete responds normally. If the results of such tests are deemed abnormal, the exam should be repeated every five minutes for the first hour, then hourly for the first day, and then daily after that until the athlete returns to normal.
Once the athlete is stable, level or loss of consciousness should be evaluated. With any loss of consciousness, the athlete should be transported to an emergency room or other medical facility. Loss of consciousness is defined as unresponsiveness to external stimuli for any amount of time and is seen in approximately 10 percent of head injuries. Any loss of consciousness or confusion lasting more than one hour warrants imaging such as an X-ray, magnetic resonance imaging (MRI), or computed tomography (CT) scan. An athlete’s level of consciousness is often determined by the Glasgow Coma Scale (GCS), a numerical scale that corresponds to various levels of consciousness; this scale is used frequently by medical personnel. The GCS includes assessments of eye opening, motor response, and visual response (see table 4.1). An injured athlete receives a score for each assessment, and the sum of the individual scores determines the head injury classification. This evaluation should be performed as part of a sideline evaluation for athletes with concussions or head injuries.
A sideline evaluation of not only consciousness but also cognitive function is essential for the assessment of a concussion. The GCS is now being used as part of a more comprehensive test known as the Sports Concussion Assessment Tool, Fifth Edition (SCAT5). This is a test generally performed by a licensed health care professional in less than 10 minutes. It is used for athletes aged 13 and older; a pediatric version also exists. The first step of the SCAT5 is recognition of red flags. These include neck pain or tenderness, double vision, weakness, tingling or burning in arms or legs, severe or increasing headache, seizure or convulsion, loss of or deteriorating consciousness, vomiting, increased restlessness, agitation, or combativeness, which may all be signs of a more serious head injury or other medical condition. Observable signs such as balance and gait dysfunction or clear evidence of facial or head trauma are first noted. Along with the GCS, a cervical spine assessment should be performed on the athlete. A brief memory assessment should be done on the sideline or field for signs of amnesia. This includes questions on venue, score, and point of time in the game.
The SCAT5 is completed in the office or off the field. This includes details on the athlete’s background, including history of concussions, noting the most recent. A full symptom evaluation notes whether symptoms worsen with physical or mental activity. A full cognitive assessment is made, including more specific orientation and immediate memory and concentration, which include reciting digits backward or months in reverse order. A neurological screen including gait and balance is obtained. Delayed recall of objects at one and five minutes is also assessed. The complete assessment should be used in determining return to play for an athlete. It is also important to obtain a preseason baseline SCAT5 evaluation, because memory, concentration, information processing, executive function, and reaction time can differ across athletes.
TABLE 4.1 Glasgow Coma Scale (GCS)
Eye opening response
Spontaneous—open with blinking at baseline
To verbal stimuli, command, speech
To pain only (not applied to face)
Confused conversation, but able to answer questions
Obeys commands for movement
Purposeful movement to painful stimulus
Withdraws in response to pain
Flexion in response to pain (decorticate posturing)
Extension response in response to pain (decerebrate posturing)
Head injury classification
Severe head injury
Score of 8 or less
Moderate head injury
Score of 9 to 12
Mild head injury
Score of 13 to 15
Reprinted from Centers for Disease Control and Prevention (www.cdc.gov/masstrauma/resources/gcs.pdf)
Even without loss of consciousness, a concussed athlete should be assessed for confusion or amnesia (see table 4.2). Confusion is defined as any impairment in awareness or orientation to surroundings. Amnesia is defined as the loss of recall of events just before the injury occurred, at the time it occurred, or just afterward. Retrograde amnesia is the inability to recall events immediately preceding the trauma. Posttraumatic amnesia (also called anterograde) is further differentiated according to the length of time between trauma and the point of regaining normal continuous memory.
TABLE 4.2 Confusion and Amnesia Assessments
Awareness or orientation to surroundings
“What is your name?”
“Where are we playing? What’s the stadium or field name?”
“Who are we playing? Who is the opposing team?”
“What day is it? Month? Year??
“Do you remember getting hit?”
“What is the score of the game?”
“What happened earlier in the game?”
Coach or trainer should repeat three words such as ball, chair, and car.
Ask athlete to repeat these words at one minute and then five-minute intervals.
Posttraumatic amnesia is no longer present when athlete can recall the words.
Sometimes athletes suddenly lose consciousness without trauma—for example, when they are engaged in an aerobic activity and suddenly collapse. In such cases, the loss of consciousness is not related to a concussion. Instead, it may be secondary to cardiac irregularities. If the athlete has neither a pulse nor spontaneous voluntary breathing, an ambulance should be called and cardiopulmonary resuscitation should begin.
Concussions sometimes cause a decrease of blood flow to the brain, which can result in postconcussion syndrome. The symptoms of postconcussion syndrome include headache, nausea, dizziness, balance deficits, visual deficits, attention deficits, and memory loss. Common visual deficits are blurriness and photosensitivity. These can occur immediately or over time. The athlete might feel fatigued or irritable and have unusual emotional or personality changes. A sleep disturbance might occur, and the athlete might become depressed. The severity and duration of the symptoms can vary from days to weeks, depending on the severity of the concussion. Headache occurs in approximately 70 percent of those afflicted and is the most common symptom of postconcussion syndrome. The athlete might experience a headache during the initial sideline evaluation, which may become more intense over the ensuing hours or get worse with exertion. If a headache becomes severe or if the athlete is vomiting or experiencing a decline in mental status, the athlete should be taken to an emergency room immediately so that a subdural hematoma (McCrory et al. 2017) or an intracranial bleed can be ruled out. Either of these conditions can be life threatening.
More postinjury difficulties involve amnesia than a loss of consciousness (Collins et al. 2003). A loss of consciousness does not necessarily signal deficits. The more symptoms the athlete has, the longer the symptoms last, and the greater the neurocognitive impairment, the more likely there will be long-term memory deficits.
If an athlete who is recovering from a concussion receives a second blow to the head, the consequences can be fatal. Second-impact syndrome is defined as massive cerebral edema, which is swelling of the brain. Clinically, the athlete demonstrates a rapidly decreasing level of consciousness.
Treatment and Recovery
If the cervical spine is determined not to be affected (see chapter 5), the conscious athlete with a head injury should be positioned upright to decrease intracranial pressure. Once sitting stably, the athlete can then stand and be helped off the field. If a cervical spine injury is suspected, protective equipment (shoulder pads, helmet) or articles of clothing should not be removed if removal might cause motion in the cervical spine area. The neck and spine should be protected with a stabilization collar, if available, or via placement of rolled-up clothing alongside the neck to secure it from motion. If unconscious, the athlete should be stabilized and the airway protected. If the athlete is not breathing and has no pulse, an ambulance should be called and resuscitation with cardiac life support is warranted. If obvious bleeding is noted, a pressure dressing (or any dressing available) should be placed directly over the bleeding site. If bleeding is profuse, the athlete should be lain down and the legs raised slightly to help return blood to the heart.
Once stable, the athlete should be transported to a hospital’s emergency room for further evaluation. The athlete will be admitted if imaging results (X-ray, MRI, or CT scan) or neurological status remains abnormal. If the results of the neurological exam and imaging studies are normal, the athlete may be released. Once the athlete is home, family members should perform regular neurological checks, which include asking the athlete the day and date, the year, or the name of the president. They should also ask the injured athlete whether any headache, nausea, or weakness is occurring. If the responses to these checks worsen, the athlete should be transported to the physician or emergency room. Concussed athletes who suffer a second impact typically require a neuropsychological evaluation and cognitive retraining.
Relative rest is recommended for 24 to 48 hours after injury; then activity should be progressed while staying below cognitive and physical symptom exacerbation thresholds. Rehabilitation is not necessary for most athletes who recover within 10 to 14 days. With prolonged symptoms, psychological, cervical, and vestibular rehabilitation may be needed. Controlling exercise at subsymptom threshold has been shown to be a safe and effective way of facilitating recovery. Cognitive stress should also be controlled using appropriate accommodations. Cognitive behavioral therapy is often necessary to address persistent mood or behavioral issues.
Recovery is generally slower in athletes with a greater number and severity of symptoms. Having a history of concussions is a risk factor for future concussions, and having experienced multiple concussions is associated with having greater physical, cognitive, and emotional deficits. The strongest predictor of slower recovery is the severity of symptoms in the initial few days after injury. Other factors associated with more persistent symptoms include migraines, anxiety, posttraumatic stress disorder, attention deficits, and sleep dysfunction.
Return to Action
All athletes regardless of level of participation should be managed the same way. Fortunately, 80 to 90 percent of all concussions resolve within 7 to 10 days without further treatment (McCrory 2008). However, 10 to 20 percent of these head injures continue with postconcussion symptoms. When determining return to play after a concussion, guidelines should be followed. No athlete with a concussion should return to play on the same day (McCrory 2008). Athletes should be allowed to return to play only when they are fully asymptomatic at rest and upon exertion. The individual should not consume medications that may mask or modify symptoms. Functional testing should always be done to elicit symptoms such as headaches, nausea, dizziness, and balance, or visual deficits associated with physical demands needed for return to play. Neurologic exams and neuropsychological testing should be normal before returning to play.
An athlete with concussion symptoms who returns to play during the resolution period is at risk for serious injury or even death. Studies suggest that even minor concussions increase the risk of developing dementia later in life (Barnes et al. 2018). Furthermore, there is now evidence that repetitive concussions can lead to chronic traumatic encephalopathy (CTE), a degenerative brain disease resulting in cognitive, somatic, and neuropsychological impairment. Therefore, it is important to follow the current six-step return-to-play guidelines known as the Zurich Protocol (McCrory 2008). These guidelines were clearly outlined at the 5th International Conference on Concussion in Sport held in Berlin in October 2016 (McCrory et al. 2017). Initial symptoms and severity of symptoms do not alter the return-to-play protocol.
An initial period of relative physical and cognitive rest for 24 to 48 hours is recommended after any concussion before beginning the return-to-play progression. Each step in the progression should last 24 hours or more. If any symptoms worsen, the athlete should go back to the previous asymptomatic level and can progress again after being symptom free at that level for at least 24 hours. If symptoms persist longer than two weeks in adults or one month in children, it is recommended that the athlete see a health care professional specializing in concussion treatment.
The first step of the protocol should not begin until the athlete is asymptomatic at rest.
Step one includes activities that do not provoke symptoms. This assists the athlete in getting back to work or school activities. Step two is light aerobic exercise such as jogging or cycling at a slower pace without any resistance. Step three is sport-specific exercise such as running or skating drills without impact. Step four is noncontact drills and progressive resistance training. Step five is full-contact practice and participation in regular training activities. This helps the athlete restore confidence and allows coaching staff to assess functional skills. Only after completing all five of these steps over a minimum of five days can the athlete advance to step six, which is returning to normal game play.
Summary of Concussion Recommendations
- Removal from game with any sign or symptoms of concussion
- No return to play on day of injury
- Medical evaluation following injury, including neuropsychological testing and radiographs to rule out more serious intracranial pathology
- Adherence to stepwise return-to-play process:
- No activity until asymptomatic at rest and during exertion
- Light aerobic exercises
- Sport-specific exercises
- Noncontact drills
- Contact drills
- Game play
Two of the most important factors in determining next steps are the athlete’s age and concussion history. Children have more prolonged and diffuse cerebral swelling and are at an increased risk for a second head injury (Pickles 1950). It is important to note that the speed of recovery is the same for all age groups, thus negating the theory that “kids heal faster.” Knowing whether the athlete has a history of concussions at the time of a new injury is important. Cumulative neuropsychological and subtle neurocognitive deficits can be seen after multiple concussions. After three or more concussions, athletes become more vulnerable to subsequent injuries (Collins et al. 2002) and therefore it is recommended that they retire from contact sports.
Overall there is a strong need for clear and practical guidelines to determine recovery and safe return to play for athletes with a sport-related concussion. One must remember that the science of concussion is incomplete, and thus management and return-to-play decisions should still be based on clinical judgment on an individualized basis.
SUBDURAL AND EPIDURAL HEMATOMA
Subdural and epidural hematomas are caused by a direct blow to the head and occur primarily in contact sports. A subdural hematoma is bleeding between the outer layer (dura) and middle layer (arachnoid) of the membrane covering of the brain, and an epidural hematoma is bleeding between the outer membrane of the brain (dura) and the skull.
An athlete with an epidural hematoma typically experiences a decreased level of consciousness and a severe headache. A variable lucid period is followed by a rapidly declining level of consciousness. A subdural hematoma or intracranial bleed results in loss of consciousness with little to no lucidity. Vomiting, seizure activity, and hemiparesis may be evident. Eye pupils are often unequal and dilated.
The athlete with symptoms of either an epidural or subdural hematoma should be immediately removed from the game and transported to a hospital emergency room. Note that the initial blow to the head causing the bleed or traumatic brain injury does not always appear to be severe.
Return to Action
Because symptoms vary so much depending on the degree of the injury, there is no set standard for return to play for subdural and epidural hematomas. Each case must be evaluated individually. Current guidelines recommend that any athlete with an intracranial bleed or lesion be out a minimum of one year, or retire completely from contact sports.
An athlete with a skull fracture exhibits different symptoms depending on the type and degree of the fracture. A skull fracture may be caused by a blunt blow to the head, a fall onto the head, or other trauma to the head. Skull fractures typically occur in contact sports such as American football but can also result from a direct hit by a baseball or hockey puck or a fall such as might occur during gymnastics or horseback riding.
A deep bruise or laceration with accompanying pain and headache signals a possible skull fracture. Other indications include sunken black eyes, bleeding from ears or nose, and swelling or discoloration behind the ear. Clear fluid draining from the nose or ears is indicative of a cerebral spinal fluid leak associated with a severe skull fracture or head injury. Unconsciousness and unequal pupils are signs of serious underlying intracranial bleeding associated with a skull fracture.
There are several types of skull fractures. A linear fracture is a simple crack in the cranium. A comminuted fracture is a crack that radiates from a center point. A depressed fracture, one of the more serious fractures, is seen when bone fragments are separated and driven inward. A basal fracture involves the cranial floor.
If the fractured pieces of skull are aligned, no treatment is generally needed; the fracture must be allowed time to heal before the athlete returns to play. A depressed skull fracture generally requires neurosurgery. Athletes with this fracture typically are treated with oxygen, anticonvulsants, and osmotic diuretics (such as mannitol) to reduce brain swelling. After the athlete is treated and becomes stable, extensive rehabilitation—including physical, occupational, and speech therapy—follows.
Return to Action
With any significant head injury, a full neuropsychological evaluation should be performed before clearing the athlete to return to play. Persistent cognitive or neurological impairment—including weakness, numbness, or balance deficits—disallows any return to contact sports.
NASAL AND MANDIBLE FRACTURES
Fractures to the nose and jaw are seen most often in contact sports. They are caused by a direct forceful blow to the face.
A nasal fracture can be identified by pain and tenderness, bleeding, and increased mobility of the nose. There is typically a displacement deformity of the nose. An athlete with a mandible (jaw) fracture has a painful and swollen jaw and difficulty opening the mouth. The athlete will have difficulty speaking and often have loose or knocked-out teeth. There might be significant facial distortion. Blunt trauma in contact sports can also result in other oral trauma, such as when lips and gums are forcefully compressed against teeth. If blunt trauma occurs to the oral region, a laceration and sometimes dislodged teeth could result.
As initial treatment for a nasal fracture, maintain an open airway by suctioning, positioning, and controlling bleeding. If there is no associated skull or neck fracture, the athlete should be positioned forward to avoid blood draining into the throat. If the athlete is unconscious, immobilize the neck first because posterior head and cervical spine injuries are often associated with nasal fractures. Nostrils may be pinched (or direct pressure applied by the pads of the index fingers placed alongside the nose) to control bleeding, unless the nose is draining clear fluid, which indicates a skull fracture. Apply a cold pack to decrease blood flow to the area.
As initial treatment for a mandible fracture, maintain an airway and dress the wound. The lower jaw should be supported and immobilized with a cravat or strap placed under the jaw and wrapped around the top of the head and tied in a knot above the ear. The athlete should then be transported to the emergency room for evaluation by an oral surgeon. If teeth are dislodged, they should be carefully removed to avoid airway obstruction.
Return to Action
For a nasal fracture, once the nasal bones are healed and the airway passage has been opened with or without surgical intervention, the athlete may return to play in approximately six weeks. The athlete should wear a protective face mask for the remainder of the season. For a jaw fracture, once the jaw has healed and the athlete is cleared by an oral surgeon to return to play, the athlete should wear a mouth guard to prevent a recurrent injury. A mouth guard should also be worn by athletes who have experienced other oral trauma.
Blunt trauma to or pulling on the ear can result in what is known as a cauliflower ear caused by a hematoma or collection of blood in the outer ear. This injury is most common in wrestling and is sometimes called wrestler’s ear.
The injury shows up as a shapeless, purplish mass on the outer ear caused by a calcified hematoma. It may cause mild to moderate local discomfort.
The mass, or clot, must be removed via an incision. This can be done in an office setting with local anesthesia.
Return to Action
Once the incision has healed, in approximately four to six weeks, the athlete can return to play.
Eye injuries are generally associated with direct trauma to the eye, such as getting poked in the eye by an opponent’s finger while going for a rebound in basketball.
An athlete may sustain any of a variety of eye injuries. With a subconjunctival hemorrhage, the athlete has a red or bloodshot eye, equivalent to a bruise to the eye. More serious eye injuries include foreign bodies and puncture wounds to the eye. A foreign body in the eye usually results directly from major or minor contact to the eye. The athlete may experience burning, pain, or discomfort in the eye. Generally, the foreign body is identified with fluorescein staining of the eye.
A subconjunctival hemorrhage will generally resolve without treatment within two weeks. If a foreign body is identified in the eye, the eye should be shut and the athlete evaluated by an ophthalmologist (eye doctor). The foreign body should never be removed or the cornea of the eye touched by an untrained professional. If the foreign body is chemical in nature, immediately and extensively irrigate the eye for 15 to 20 minutes with water or a saline solution that is flushed into the eye. Antibiotic ointment and a patch should then be applied. The athlete should be evaluated by an ophthalmologist to rule out further damage to the eye.
If the eye injury is traumatic, a medical professional will need to check for eyelid perforations or corneal abrasions. These injuries are extremely painful, and initial treatment is often aimed at pain control. A cup or loose protective dressing should be placed over the injured eye and the athlete transported to an emergency room for evaluation by an eye doctor. The pupils are then dilated with atropine and antibiotic eye drops are applied.
Return to Action
A subconjunctival hemorrhage will generally not keep an athlete from returning to play. Once the foreign body has been removed, the cornea healed, and normal vision restored, the athlete may return. Return time depends on the extent of the corneal abrasion. Direct penetrating trauma, usually with a sharp object, results in a puncture injury to the eye. Return to play after a puncture, chemical, or blunt injury requires full healing and clearance by an optometrist or ophthalmologist.