Dr. Monique S. Burton Cahn, orthopedics specialist, presents a case of a concussion in a 15-year-old soccer player.
A 15-year-old female soccer player presents to clinic for evaluation of concussion. Three days ago, during a soccer game, she went up for a header at the same time as a player on the other team when their heads collided. There was no loss of consciousness (LOC); however, she felt slight dizziness, nausea and saw "spots" for a few seconds. She states she "shook it off" and continued to play the remainder of the game, which was about 20 minutes. During that time, her headache seemed to get a little worse and she felt kind of "out of it." After the game, she did not report symptoms to her athletic trainer or coach and went home.
That evening, she had a persistent headache, felt fatigued and was more irritable with her family than usual, so went to bed early. Her parents were not at the game, so they were unaware of the injury, but did note her moodiness as well.
The following day, she went to school when she noted difficulty concentrating and focusing in her classes. Her headache got worse throughout the day along with not wanting to hang out with her friends as usual during lunch.
She decided to check in with her athletic trainer after school. Her athletic trainer evaluated her using the Modified Sport Concussion Assessment Syndrome - 2nd Ed - Tool (SCAT2) (derived from the 3rd International Conference on Concussion in Sport - see reference #4) and assessed the patient as having a concussion. She was encouraged to follow up with her medical provider; in addition, she was given recommendations of physical and cognitive rest. This athlete was also encouraged to return to the athletic trainer for a follow-up on her baseline ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test once she was symptom-free.
During her office visit (three days after injury), she reported symptoms of headache, pressure in the head, nausea, dizziness, sensitivity to light and noise, sleep pattern changes, feeling slowed down and "in a fog," "don't feel right," difficulty concentrating and remembering, fatigue, feeling more emotional, irritability and sadness. She notes that her symptoms did get worse with mental activity and walking around at school.
Occasional ibuprofen; however, it did not seem to be helping the headaches.
Past Medical History
- Significant for history of one previous concussion about three years ago while playing soccer. She was playing goalie and collided with another player very hard, causing her to fall to the ground with a whiplash-type of motion of her neck, but did not actually hit her head. No LOC. Symptoms lasted for about one week, and then she gradually returned to activity without complications. She has been doing well since, without decline in school performance or any residual symptoms.
- No history of learning disabilities, attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD), seizure disorder, migraine headaches, anxiety, depression or other psychiatric conditions.
Mom with history of migraines.
She is in 10th grade and plays year-round soccer on a select team. She enjoys school and has a 4.0 grade point average (GPA).
- General: WDWN (well-developed, well-nourished) female in no apparent distress (NAD)
- Neurological examination: Cranial nerves II-XII grossly intact, fundoscopic examination normal, deep tendon reflexes +2 throughout upper and lower extremities, cerebellar intact, no ataxia, negative Romberg
- Concussion Evaluation: Modified SCAT2 (PDF):
- Orientation Score: 5/5 (Figure 1, page 1)
- Immediate Memory Score: 14/15 (Figure 2, page 1 1)
- Concentration Score: 3/5 (Figure 3, page 1)
- Coordination Score: 1/1 (Figure 4, page 1)
- Delayed Recall Score: 3/5 (Figure 5, page 2)
- Balance Examination Score: 6/30 (Figure 6, page 2)
- Physical Signs Score: 0/2 (Figure 7, page 2)
- Symptoms Score: 16/22 (Figure 8, page 2)
- Part 1 Score: 26 (Figure 9, page 3)
- Part 2 Score: 33 (Figure 9, page 3)
- Total Score: 59 (Figure 9, page 3)
A very detailed discussion with the patient and the family included the following recommendations:
- Rest from all physical activities, including sports, physical education class, extra training on the side, personal workouts, etc.
- She could continue to do the necessary physical activity to go about her day such as walking to and from classes.
- After careful discussion about her symptoms while at school, she felt she could attend about two classes before her symptoms started to increase. Therefore, we made the decision to start with two classes and add classes as her symptoms improved.
- She was given a detailed written note for her teachers and school counselor with recommendations for accommodations that included reduced workload, increased time for assignments, and postponement of exams until she was feeling better. Other recommendations to avoid flares in her symptoms included arranging to leave class a few minutes early to avoid the noisy hallways; spending lunch in a quiet, calm area; and excusing her to the library or quiet area to do work if the classroom noise was too challenging.
- We discussed minimal TV and computer usage along with limiting texting to only necessary brief communications. She was not a video game player.
- We discussed decreasing her social schedule to allow for ample rest. She was quite emotional about this, given it was homecoming that upcoming weekend. After a lot of negotiating, she decided she would not go to the homecoming football game, but would go to the dance for a limited time to see her friends. While at the dance, she would not dance and plan to come home early. She would also plan to rest over the remainder of the weekend from other social activities.
- We discussed eating a regular, healthy diet to ensure adequate nutrition in addition to consuming plenty of fluids to avoid dehydration.
- We also disused the importance of good sleep hygiene. Although she may require a bit more sleep, we recommended a normal sleep/wake pattern and if she were taking naps, to take short naps earlier in the day rather than later.
- She followed up with her athletic trainer daily to report her symptoms. Her symptoms gradually improved over the next week, which allowed her to increase her school time slowly.
- At her one-week follow-up visit, she was completely symptom free. Her Modified SCAT2 was repeated and significantly improved from her previous evaluation. She was released to begin a gradual progression back to physical activity with the guidance of her athletic trainer.
- The following day, her athletic trainer repeated her ImPACT (computerized neuropsychological testing) and it was comparable to her pre-season baseline. She began a gradual progression back to physical activity over the next five days under her athletic trainer's guidance. She was able to progress through each step successfully and return back to full practice and game play without complications. Prior to her full practice, a written note of medical clearance was given to her from our office.
The International Conference on Concussion in Sports defines concussion as a "complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces." Concussions may occur as a result of a direct blow to the head, face, neck or elsewhere on the body with an "impulsive" force transmitted to the head. Typically there is a rapid onset of relatively short-lived impairment in neurological function that resolves spontaneously in a sequential manner. Fortunately, most sports-related concussions do not result in a structural injury; however, they certainly must be evaluated for that potential.
There are about 1.6 to 3.8 million sports- and recreation-related concussions in the United States each year. Although football ranks at the top of the list for concussions, followed by girl's soccer, boy's soccer and girl's basketball, concussions occur in any sport and should be carefully considered when any impact to the head or body occurs. While loss of consciousness should be considered in concussion management, it occurs in less than 10% of sports-related concussion.
With each concussion, the risk of subsequent concussion increases, ranging from about 1.5 times the risk with one previous concussion to 3.5 times the risk with three or more previous concussions.
Multiple factors may contribute to the speed or length of recovery. Underlying risk factors for potential challenges in recovery include history of learning disability, ADD/ADHD, seizure disorder, migraine headaches or anxiety, depression and/or other psychiatric conditions. Other common factors that contribute to prolonged symptoms include failure to report symptoms after injury, continuing to play and/or practice, and participation in too many social and cognitive activities.
Although the average length of recovery for concussions in high school students is about 10 to 14 days, this certainly varies and depends on multiple factors, including those listed earlier.
The most concerning issue of returning to play too early is second impact syndrome. This occurs when a patient suffers from a head injury and then sustains another head injury prior to complete recovery from the first. A catastrophic cascade of events occurs that can lead to significant impairment or death.
- A detailed history should include mechanism of injury, immediate post-injury symptoms and the progression or change in symptoms since the injury until their office visit, types of physical activities they have been doing since the injury, ability to go to school or not and other social activities they may be participating in. Underlying risk factors, as mentioned earlier, should be accounted for and any other relevant family history and social history.
- A symptoms scale, such as found in the SCAT2, is very helpful to understand current symptoms as well as to follow throughout recovery.
- The physical examination should include a basic neurological examination; however, it is more detailed for any focal findings. Use of the SCAT2 in the office is a very useful concussion evaluation tool (as earlier in our patient). It includes a cognitive assessment of orientation, immediate memory, concentration, coordination, delayed recall, a balance examination using the modified balance error scoring system (BESS), a physical signs assessment of loss of consciousness and balance problems and symptoms scale. The SCAT2 evaluation can be followed as the patient recovers and before they return to activity to help provide additional supportive information in determining when the athlete is ready to return to activity.
Neuroimaging is not typically indicated unless there are focal findings or lack of improvement of symptoms. A CT scan may be performed acutely in concerning patients; however, with prolonged symptoms an MRI is the study of choice at this point in time.
Very detailed and clear recommendations should be given to help patients recover safely and most efficiently from their concussion. Unfortunately, there are not any medications or other treatments that make concussions recover more quickly, making physical and cognitive rest the essential components of management. (See aforementioned treatment plan for this patient for detailed recommendations.)
In order to minimize the potential for prolonged symptoms or devastating consequences, the patient should only begin a return to play/physical activity plan after all symptoms have completed resolved and the patient feels 100% back to their baseline. The plan should be progressive and gradual to ensure there has been adequate recovery and symptoms remain resolved as they progress back to activity. Following are the recommendations per the International Conference on Concussion in Sport:
- Step #1: Light aerobic activity for about 20 minutes (examples - brisk walk, stationary bike without resistance, etc.)
- Step #2: Moderate aerobic activity for about 20 minutes (examples - jogging/running, elliptical, etc.)
- Step #3: Non-contact sports-specific drills (examples - sprinting, cutting, sports-specific drills)
- Step #4: Full practice
- Step #5: Full game play
In Washington state, a written note of medical clearance is required before returning to full practice.
Computerized neuropsychological testing has become a very common tool in concussion management (common examples are ImPACT, CogSport, etc.) A pre-season test is performed to establish a baseline. When the athlete feels they have recovered from their concussion, the test is repeated to help ensure their cognitive status has returned to baseline before returning back to full play.
Formal neuropsychological testing may be considered in select patients, including patients with prolonged symptoms, as well as patients with complex histories and multiple concussions.
Zackery Lystedt Law
In Washington state in May of 2009, Governor Gregoire signed House Bill 1824, which is known as the Zackery Lystedt Law. This law states that any athlete suspected of sustaining a concussion or head injury during practice or game must be removed from their sport at that time. They may not return to play until they are evaluated by a licensed healthcare provider trained in the evaluation and management of concussions and receive a written letter of medical clearance from that person.
Sports-related concussions are very common. Any concern for possible head injury should be evaluated carefully for signs and symptoms of concussion and treated accordingly as noted earlier. Patients with underlying risk factors may present challenges in recovery from concussions. Patients with history of multiple concussions should be carefully evaluated on an individual basis because they present additional challenges in determining appropriate management as well as what sports may or may not be recommended. If available, athletic trainers are very helpful and important resources for young athletes. Direct provider-to-athletic trainer communication is recommended to provide optimal care for patients. Although the recommendations noted earlier are a useful template for patient care, each concussion is different, not only from patient to patient, but from injury to injury within the same patient, and careful individual management will provide for the safest and most efficient recovery.
Indications for Referral
Consider referring athletes with concussion to a specialist trained in concussion management if any of the following conditions are noted:
- The concussion symptoms are prolonged and last over two to three weeks. As stated earlier, the majority of concussions in high school athletics resolve in 10 to 14 days or sooner. Also, referral should be considered if the concussion symptoms are showing no improvement.
- There is a history of multiple concussions. Return-to-play decisions can be difficult, especially in cases where athletes have had multiple head injuries.
- There are concomitant factors, such as a history of seizures, psychiatric disorders, significant headache disorder or past subdural hematoma or epidural hemorrhage.
Any patient with a new focal neurologic finding on exam or recent history of recurrent vomiting should be considered for emergent evaluation for acute progressive head injury. (Send kids to the emergency room with an abnormal neuro exam or if they have vomited more than two to three times in the past 24 hours.)
- Collins MW, Field M, Lovell MR et al (2003) Relationship between postconcussion headache and neuropsychological test performance in high school athletes. Am J Sports Med 31 (2):168-173.
- Guskiewicz KM, Weaver NL, Padua DA et al (2000) Epidemiology of concussion in collegiate and high school football players. Am J Sports Med 28:643-650.
- Guskiewicz KM, McCrea M, Marshall SW et al (2003) Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA concussion study. JAMA 290 (19):2549-2555.
- McCory P, Meeuwisse W, Johnston K et al (2009) Consensus Statement on Concussion in Sports 3rd International Conference on Concussion in Sports Held in Zurich, November 2008. Clin J Sport Med 19 (3): 185-195.
A special thank-you to the Seattle Children's Sports Concussion Program team members, Saboora Deen, ATC; Jeanette Kotch, PA-C, ATC/L; Brian Krabak, MD, MBA; and Thomas Jinguji, MD, for reviewing and commenting on this case.
For more information, please contact Orthopedics and Sports Medicine.