Back in the days when the skull and brains were made of steel and ships were made of wood, considerable liberty was taken with the “squash” without realizing the short- and long-term consequences. After all, he was just an already dumb lineman or punch-drunk fighter. (In reality, the punch-drunk fighter should have been an early warning that something wasn’t right.)


Published 1/1/2014
S. Terry Canale, MD

Boy, what a hit—he rang my bell!

Back when there were no helmets, later when there were helmets but no facemasks or mouth guards, and even today when helmets contain extra padding or “bladders,” concussions or mild traumatic brain injuries were and still are common.

Not long ago, trainers, coaches, and even team physicians would chuckle when a player staggered to the sideline after a vicious hit. “Boy, he just got his bell rung!” they might say. Then they’d ask if he knew what day it was. If he didn’t, they’d ask what game he’s playing and how many fingers he could see. When he got it right, he could go back in. If they remembered, they’d check to see if both pupils contract.

S. Terry Canale, MD


But not today, thanks to the likes of Richard G. Ellenbogen, MD, a neurosurgeon from Washington state who serves as cochair of the National Football League’s (NFL) Head, Spine, and Neck advisory committee, and orthopaedic pioneers like Joseph S. Torg, MD, of the Temple University Concussion and Athletic Neurotrauma Program, and now Barry P. Boden, MD, of the Orthopaedic Center in Rockville, Md. Finally, the catastrophic results of concussions are becoming apparent as we turn over one lobe after another and find more damaged commissures in the brains of former players.

Concussions occur most commonly in motor vehicle accidents, wars, and sports. Most concussions in sporting events are inflicted by participants on other participants, often observed by thousands of spectators, condoned by millions of enthusiastic TV watchers, and tolerated by organizers, team trainers, and physicians.

Is it just me or do you find it peculiar that concussions in sports rank right up there with auto accidents and wars?

The long-term effects of concussion, whether single or multiple previous unrecognized events, have recently been described and include noticeable long-term brain damage, occurring as Coach Pepper Rogers noted in his novel Fourth and Long Gone.

I could go on for another “half” but, no, not another “quarter,” not a 2-minute warning or overtime, not another minute—we need to do something now!

What can be done?
One obvious solution is to ban collision sports as Dr. Charles W. Eliot, president of Harvard (1869-1909), did when he banned American football at that Ivy League bastion. I guess that could happen at Harvard, but it ain’t gonna happen at ’Bama! And it ain’t gonna happen in my lifetime, so I can just get off that soap box and forget that idea for now.

The second most obvious solution is to change the rules and equipment significantly. Women have a high number of concussions in organized sports such as field hockey, lacrosse, and soccer. Why? Gender differences? No helmets? The Princeton, N.J., public school system courageously mandated that soft helmets be worn by boys and girls participating in soccer, field hockey, and especially girls’ lacrosse. Naysayers responded that helmets don’t work, they’re expensive (about $70 each), and those wearing helmets have an advantage over those who aren’t.

So, as you can see, changing rules and/or equipment requirements would be difficult and would almost certainly be political and might have to be legislated.

Dr. Ellenbogen once appeared before a Congressional committee and testified about the “concussion epidemic.” One senator actually challenged him, asking why he could not “cure” this epidemic. So, the political route to change rules and equipment won’t be easy but can be done.

Professional and college organized sports, leagues, and teams have thrown task forces, work groups, forums, and finances at the problem, but with no resolution. Do you think for one minute that the World Cup is going to take “headers” out of soccer? No way! Recently, the NFL settled a lawsuit with more than 2,000 former players who had sustained concussions and long-term brain damage; the settlement was $1 billion—a drop in the bucket to that organization, but a great PR move to make the problem go away. Now, former college players are suing the National Collegiate Athletic Association on the same grounds.

Research and treatment
Less obvious solutions are research and treatment. So far, research has made little progress as far as reducing the concussion rate with innovative new equipment. Helmets with bladder liners may have actually increased the incidence.

That leaves treatment, preventive and curative. I believe preventive measures may help dramatically cut down on recurrent concussions and long-term consequences. “One, two, three—take a knee.” As noted by Dr. Ellenbogen in this month’s article in AAOS Now (“Concussions: Doing the Right Thing”), it is time to do the right thing. So, as an orthopaedist, I think there are five things we can do.

  1. Support efforts to make the public, legislators, universities, and professional and amateur teams aware of the seriousness of concussions. Presently, the NFL, the National Institutes of Health, and the Centers for Disease Control and Prevention have thrown $100 million at research to find out more about prevention and treatment of concussions, but still more needs to be done.
  2. Initiate rules and penalties. Dr. Ellenbogen mentioned that rules work if they are put in place appropriately (with financial penalties). The hard part is getting them passed or legislating rules and penalties by governing bodies.
  3. Alert AAOS members, neurosurgeons, family practitioners, emergency department physicians, and any other medical professional who have anything to do with sports teams about the number of concussions, the subtle symptoms and diagnosis, and new research concerning the long-term deleterious effects of concussions. AAOS Now has published eight articles since 2011 on the subject, with more to come; the Journal of the AAOS has published review articles, and other orthopaedic publications regularly report on research being conducted.
  4. Answer the bell. Those taking care of concussions should not avoid the issue by saying, “That’s not my problem. Concussions are neurological or neurosurgical problems.” There are not enough “neuros” to stand on the sidelines of every big game, much less at all of the little games. If you are involved, concussions become your problem—at least temporarily. The following treatment slogans may help:
  • “Hit a knee, you are out for at least the rest of the day.”
  • “You can play another day, but not today.”
  • “When in doubt, sit them out!”

Furthermore, the AAOS, along with the American Orthopaedic Society for Sports Medicine and others, has developed a consensus statement about what is the least amount we should know about concussions—read it!

  1. If all of this is giving you a concussion, perhaps this will ring your bell: The whole team means more than any one player. But one injured player is more important than the whole team. Always do the right thing!

S. Terry Canale, MD, is editor-in-chief of AAOS Now. He can be reached at

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