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Breaking the Code of Silence

Honest Self-Reporting Of Concussion Symptoms Critical

Chronic under-reporting is ongoing concern


If you play a contact or collision sport, whether at the youth, middle school, high school or the collegiate level, there is a pretty good chance that at some point in your athletic career, you have had your "bell rung" or been "dinged" at some point (likely more than once). [9]

If you are like most athletes, you may not appreciate precisely when you have suffered a concussion (especially since symptoms may not appear right away), or because you don't understand the symptoms, or do not appreciate the seriousness of brain injury, [1,2,3,9,10,13] or think that you need to experience a loss of consciousness (LOC) in order to have suffered one - even though it is a myth that concussion requires such a black out, and 90-95% of all concussions in high school sports do NOT involve an LOC. [4]

Code of silence

Injured football playerEven if you suspect you have suffered a concussion, like a lot of athletes (as many as 40% according to a 2013 study [9] or an astounding 78% of university athletes in a 2014 study [12] you may be reluctant to self-report symptoms of a concussion because your parents, your coach, and the very culture of the contact or collision sport you are playing encourages you to remain silent in order to:

  • avoid jeopardizing your spot in the starting lineup or letting your teammates down;[1,9,10,11,12]
  • avoid being seen as weak or cowardly by your coach and/ or your parents or teammates;[1,9,11]
  • demonstrate to the coach and your teammates that you can "take a hit like a man;"
  • show that you can be as tough as your professional heroes;
  • stay in the game and do not want to be pulled out of the game or practice; [5,9,10,11,12, 13] or
  • because you believe that the glory of individual and team success, the promise of a college scholarship, or the lure of a lucrative professional career, is somehow worth the risk of lifetime impairment from continuing to play with concussion symptoms.

When interviewed by MomsTEAM's Brooke de Lench for the PBS documentary, "The Smartest Team: Making High School Football Safer," nearly every football player at one Oklahoma high school acknowledged that they would not self-report concussion symptoms:

  • "If I can get up and walk away from it, yeah, I'll probably keep playing."
  • "You see some dots and they go away ... so you just keep playing through it. It's my senior year."
  • "As long as I can still see and keep my balance. As long as I'm not feelin dizzy, head injuries are all right."
  • "There was a time that I've gotten a concussion. I didn't think much of it, you know, just a headache, move on with it, keep playing. ... Got hit pretty hard, helmet to helmet, couldn't see, saw stars everywhere, just went back on the field, started playing again. Didn't, didn't need to tell anyone. I mean it's not like I was laying down, couldn't get up or anything. But I thought I was fine."

But know this: If you don't tell anyone that you or a teammate are experiencing concussion symptoms and continue to play, you may be putting yourself or your teammate at increased risk of more serious brain injury, a longer recovery time, and, in very rare circumstances, catastrophic injury or even death (e.g. second impact syndrome).  Repeated concussions may also result in progressive and cumulative neurologic and neuropsychological impairment, with research showing that athletes who sustain multiple concussions may be more at risk for early cognitive impairment and depression later in life.[12 @ notes 14-22)]

Several years ago, a segment of HBO's Real Sports on high school sports concussions featured the tragic story of Ryne Dougherty, a Montclair, New Jersey football player who died in 2008, likely from second impact syndrome, when he suffered a blow to the head when he returned to play, despite having confide to teammates that he was still experiencing headaches from an earlier concussion.

As needless as Ryan's death was, even more shocking was that his teammates, when asked if, knowing what they knew now about the dangers of playing with concussion symptoms, they would still hide their concussion symptoms in order to play, they still all answered without equivocation, "Yes."

Indeed, an ESPN poll of players, coaches, parents and athletic trainers in 23 states [6] found that players like you - the ones whose brains are being rattled and who are putting yourself at risk of adverse long-term health consequences from concussions - are still the group least concerned about concussions.

When asked whether, if a star player got a concussion, they would rather lose the state title game as he sat out than win it because he chose to play with a concussion, more than half (54.1%) of the 300 players in the ESPN survey said they would play the star compared to 9% of athletic trainers, 6.1% of parents, and 2.1% of coaches. A majority of players (55.4%) also felt that a headache - far and away the number one reported symptom of concussion - shouldn't disqualify them from returning to the same game.

It is therefore critically important, as an athlete playing a contact or collision sport (including not only football, hockey and lacrosse, but soccer, basketball, cheer, and baseball), that you understand the symptoms of a concussion (things you feel) as well as the range of damaging health consequences of not reporting them, from making another concussion much more likely to long-term cognitive (concentration, memory, reasoning) and emotional difficulties (e.g. depression) to catastrophic injury or death (e.g. second impact syndrome).

Not only do you need to report your own symptoms, but, if your teammates tell you they are experiencing concussion symptoms, you should urge them to report them to some responsible adult, whether it be the coach, athletic trainer, school nurse, or parent. By doing so, you may be literally saving their lives.

Signs and Symptoms of Concussion

If you experience any of the following signs or symptoms, you may have suffered a head injury, which you should report to your coach, the trainer, and your parents, so appropriate management, including monitoring for deterioration, can begin:


Symptom Evaluation:
How do you feel?
Time of Injury 2-3 hours post-injury 24 hours post-injury 48 hours post-injury 72 hours post-injury
    N/A N/A N/A N/A
"Pressure in head"          
Neck pain          
Nausea or vomiting          
Blurred vision
Balance problems          
Sensitivity to light
Sensitivity to noise          
Feeling slowed down
Feeling like "in a fog"
"Don't feel right"          
Difficulty concentrating          
Difficulty remembering          
Fatigue or low energy
Loss of orientation          
Trouble falling asleep          
More emotional
Nervous or anxious

Return to play

It is also critically important that you NOT return to play before your symptoms have cleared. As anxious as you may be to return to the playing field, coming back too soon, before your brain has fully healed, will likely delay your recovery, but could have tragic consequences. Because your brain is still developing, a second blow to your head before your symptoms have completely cleared, not only at rest but with exercise, could lead, in rare instances, to an often fatal condition called second impact syndrome.

One recent study [7] suggests that, if you are like most athletes, in gauging your own readiness to return-to-play you are likely to rely most heavily on the absence of somatic (e.g. physical) symptoms such as headache, vomiting and visual disturbances - which are more apparent and easier for you or those around you to directly observe - and much less on the more elusive and subtle symptoms of concussion such as "fogginess," difficulty concentrating or remembering, and slowed reaction time -  which are harder for you to detect. The study also found that, if you are like most athletes, your awareness of your own cognitive decline after concussion is limited.Head with colorful question mark post-its

"The results of the study indicate youth athletes are basing their perceptions of recovery from concussion primarily on overt, physical symptoms such as headache and nausea, and may neglect to consider the cognitive symptoms of the injury, says lead author of the study, Natalie Sandel, B.S., then of the Department of Neuroscience and Dietrich School of Arts and Sciences at the University of Pittsburgh.

Another  recent study [8] found that about a quarter of athletes who report being asymptomatic after exercise - which is a prerequisite to return to play - scored significantly less than their baseline on neurocognitive tests of verbal and visual memory, so that, absent honest self-assessment of symptoms after exercise and neurocognitive testing, there is a risk that you will be allowed to return to play before your brain has fully healed.

The bottom line: be honest, be smart, and, when in doubt, sit the game out!

1. McGrath N. Supporting the Student-Athlete's Return to the Classroom After a Sport-Related Concussion. J Ath. Tr. 2010:45(5):492-498.

2. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players - Implications for prevention. Clin J Sport Med 2004;14:13-17.

3. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus 2012; 33 (6):E11 (published online ahead of print)(accessed December 10, 2012).

4.  Meehan W, d'Hemecourt P, Comstock D, "High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management" Am. J. Sports. Med. 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc)

5. Echlin PS, Skopelja EN, Worsley R et al. A prospective study of physician-observed concussion during a varsity university ice hockey season: incidence and neuropsychological changes. Part 2 of 4. Neurosurg Focus 2012;33(6):E2. 

6.  "Concussion Confidential" ESPN The Magazine (http://sports.espn.go.com/espn/news/story?id=5925876)(accessed December 21, 2010). 

7.  Sandel N, Lovell M, Kegel N, Collins M, Kontos A. The Relationship Of Symptoms and Neurocognitive Performance to Perceived Recovery From Sports-Related Concussion Among Adolescent Athletes. Applied Neuropsychology: Child. 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012).

8. McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP. Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Injury 2013;27(1):103-113. 

9. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW.  Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study.  J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)

10.  Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)

11. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.

12. Delaney JS, Lamfookon C, Bloom GA, Al-Kashmiri A, Correa JA. Why University Athletes Choose Not To Reveal Their Concussion Symptoms During A Practice Or Game. Clin J Sports Med. 2014;0:1-13; doi: 10.1097/JSM.0000000000000112 (published online ahead of print with post-publication corrections, June 19, 2014).

13. Research Abstract. "The Reporting of Concussions Among High School Football Players, an Updated Evaluation." Minor JL, MacDonald J, Meehan WP. Presented at American Academy of Pediatrics National Conference and Exhibition, Washington, D.C. October 24-27. 

Most recently revised October 23, 2014