Yesterday I wrote about concussions and the difference between professionals and adolescents using Jamaal Charles as an example. What happened last night on the professional field with millions watching was completely unacceptable, professional athlete not withstanding.
Late in the third quarter of the game, last night, San Diego’s defensive back Jahleel Addae (#37) ran into a pile to finish the tackle on the Denver running back. He was running at full speed and led with his left shoulder, but as he made contact with the RB his head dropped and he also made (incidental) helmet to helmet contact with the runner. This type of collision is very frequent and looked innocuous… Until you saw the after math…
Addae was bounced back, still on his feet, and began “short circuiting” for the national audience to see. He begins to look around, kind of, and stumble, kind of, and lose full control of his extremities, all of them. As a medical professional and athletic trainer I would have documented this OBJECTIVE finding as “unsteadiness and disorientation”. It looked like a boxer/MMA fighter catching a fist/kick in the face late in a boxing match; the type of reaction that any referee in those sports would stop a match for and award a TKO to the other guy.
It happens from time to time in this and other sports, that is not the issue here. The issue is that Addae returned to the game (oh, it gets worse). Here is the tweet from last night (h/t to Brady Phelps’ Vine);
From what I can piece together this play was the last of the 3rd quarter and reports had him taking the field on the first play of the 4th quarter. HE DIDN’T MISS A SINGLE SNAP! Even with the long commercial break between quarters there is a maximum of 4 minutes, but if my DVR time was correct it was between 2 and 3 minutes. This is not nearly enough time for a full concussion evaluation, by anyone.
“Maybe he was screened, like you said yesterday, Fink.”
There was absolutely no reason for a cursory “screen” in this situation, Addae showed a clear and overt sign of neurological impairment, in concussion recognition jargon: a sign. When any player shows a sign there is no screen it means they get evaluated. In my book and the way I evaluate for concussions the sign doesn’t even get an evaluation, they get their helmet taken, coach notified player is done and parents are summoned to the sideline (further evaluation is done after to asses if case is emergent);
“Maybe no one saw it, like you have mentioned before, Fink.”
Although this is plausible, it cannot be used in this case, in my opinion. The NFL employs an “eye in the sky” – an athletic trainer watching from above and on video – who is watching for such circumstances; if “untrained” eyes can catch this in real-time and post on Vine and YouTube there is no excuse for this being missed, period. Let us not forget all the trained eyes on the medical staff and the independent neurologist on the sidelines. Heck even the opposing team could have seen it.
Although the injury and presentation following was a classic case of normal brain function, the fact that he was returned was abhorrent. However, later on Twitter I came to find out it was even worse than this short period of time, Addae possibly experienced an earlier incident. The following is a Vine (h/t Mike Costa) from the FIRST PLAY of the game;
1. Addae loses voluntary control of his body and falls to the turf, again a sign.
2. It was right in front of the San Diego bench with a clear view of the aftermath.
3. He obviously returned to play.
4. The innocuous hit in the 3rd quarter is now much scarier, because it demonstrates that less force was needed for him to exhibit neurological impairment.
HOW CAN THIS CONTINUE TO HAPPEN?
It reminds me of the Chicago/Atlanta game, two weeks ago, when defensive back Chris Conte ran into a pile for a tackle, not unlike Addae, and once he made contact he immediately grabbed his head and went down. Although I don’t have any Vine’s of that, I know many people saw it on Twitter.
“They called Addae’s injury a stinger, you weren’t there you don’t know, Fink”.
They called Conte’s injury a neck injury, too, but lets not get caught up in the nomenclature. I can speculate for days and be told I am wrong and I have no idea; that is fine I can understand the reasons for this, but I know what my extremely trained eyes see. I see it all the time in my job.
Back to Addae, even if they want to classify it as a stinger – which is possible with the mechanism of injury – there was additional brain involvement. Stingers do not effect the lower limbs as evidenced in the first Vine.
This type of incident provides us with a learning/teaching point, from the overt sign to the case of mismanagement. But, we are beyond teaching points in this constant evolution of the concussion issue. This case, hopefully limited to this level of sport, is one that can be emulated at the levels below. In fact, I had a player tell me just yesterday that “‘X’ player played with a concussion last week why can’t I?”
Yes, it happens. Not only the younger players falsely thinking they can do what professional players do, but they also mimic the style of play and techniques they see at that level. There is a 100% trickle down effect of what people see at the professional level, in all sports (similar conversations with soccer players in reference to World Cup incidents). This is a time to put forth the effort to make sure this type of situation does not happen at any level. If this were to be repeated in the younger ages, instead of talking about a player missing some time with a concussion we could be talking about a kid losing their life due to second impact syndrome (reminder that SIS has only be documented in developing brains, not adults).
Do better!
The Concussion Blog 
“It looked like a boxer/MMA fighter catching a fist/kick in the face late in a boxing match”
Dustin, this behavior post injury, is consistent with a vestibular trauma event, not coup contra cuop, where the athlete may lay on the ground or go directly to the sideline to sit. Experts in the field now have proven in research, 50% of all these reported events are of vestibular nature. Just like a standing ten count in boxing, the player is able to shake it off and “suck it up” after regaining consciousness. I have experienced this myself as a Div 1 NCAA athlete, I have also experienced coup injury, from my experience, they are very different. One is debilitating while the other is Just temporary in most cases.
The real question that is not being asked in this forum or focused on is, do these Micro trauma, dings, dizziness, nausea, inner ear trauma, contribute to the initiation of CTE in the medial temporal lobe. More importantly, what is the mechanism that makes one prone to these events and what can we do to lower the risk of injury. Thousands of retired athletes are living healthy lives after playing football at the highest level, yet for some “unknown reason” a sub set of these athletes develop CTE.
Why. The only documented evidence in the books that we have is in Boxing. The glass jaw leads to the Punch drunk boxer and in the end Pugilistica dementia, now known as CTE.
Mark,
The broader discussions of coup contra coup and vestibular injuries aside. The point Dustin is making here is not what the injury was, but the fact that there was apparently no evaluation done. Even a vestibular injury should have needed a few minutes to rule OUT a coup contra coup injury.
There was barely enough time to ask “How do you feel?” let alone do anything more than a cursory screen. If the second hit was the only one he took, maybe the sideline doesn’t see how bad it was and clears quickly. Maybe also that happens if the first hit was only a stinger. Put the two collisions together and it screams for a longer evaluation.
I’ve seen dozens of stingers live in the last decade and a half and NONE have ever looked like that second hit. Maybe it was a vestibular/TM injury with no coup contra coup involvement. No where on this planet could you be fast enough to figure that out over a 3 minute commercial break.
The “Wow, did you see that?” followed by the “He’s staying tuff and staying out there.” type of comments you usually see with situations like this is why football has a concussion problem.
Bryan, all players should be removed from the game to evaluate regardless of the type event. But vestibular events occur routinely during play and many times the player is able to hide the injury and stay in the game. This is why we need to find out what is the cause/mechanism of the vestibular issue, is it inner ear, cervical spine or Ocular. Prior to play evaluations with the correct diagnostics can give some clue’s to why, one player is having more events than the others. Unlike sensors this is a direct approach.
https://vestibular.org/news/07-29-2014/it-really-concussion-symptoms-overlap-neck-injuries-making-diagnosis-tough-call.
http://www.ncbi.nlm.nih.gov/pubmed/23087786
This recent research display’s the need to be evaluated for the individuals specific orthopedic/postural issues prior to play. Testing equipment now available enables precise measuring of neuropaths and muscle activity to find any noted deficiencies. Identifying and correcting these orthopedic issues is crucial, ignoring them many experts believe, has been a major mistake.
Remember, one cannot diagnose concussions on TV. The NFL said so.
The NFL sets undeniably the worst examples for young players and makes Docs and ATCs miserable.
Concussion dx needs to be removed from the NFL influence entirely. Until the NFL is held to account and financially to account this will continue.
Dustin, I could not agree more. It is adding insult to injury to try to pass this off as a “stinger”. Even lay people can recognize that he had a significant neurologic event that needed immediate attention. To try to claim otherwise is insulting.
Mark Picot – maybe I am a poorly trained medical professional, but I have not heard of a vestibular trauma event. I’d love for you to provide a link to your statement that “Experts in the field now have proven in research, 50% of all these reported events are of vestibular nature”. Are you arguing that the Charger player in this case has a temporary injury that he could shake off very quickly and return to play without concern? If so, how can we know that the player is not lying and does not have a mild traumatic brain injury?
And I’ll continue with your second post, which seems to come from nowhere in the context of the blog post: but I will strongly argue that a n=1 is not research. The results from your linked case report article could be placebo effect. I’d like to see actual research methodology and a larger sample size, controlled study to show that gnathological postural treatment is beneficial. In my PubMed search, I was able to find a study of 7 swimmers (again not great research but interesting). If there is actual scientifically proven benefit, I’d love to improve my knowledge.
maybe I am a poorly trained medical professional, but I have not heard of a vestibular trauma event. I’d love for you to provide a link to your statement that “Experts in the field now have proven in research, 50% of all these reported events are of vestibular nature”
Temporomandibular Joint Disfunction (TMJ) or physio-postural pathologies owing to the consequent alteration of the “tonic-postural system”
“tonic-postural system”
http://www.souletbesombes.com/information-clinical-cases.4.html
http://bangordailynews.com/2014/09/25/health/new-test-detects-concussion-impairments-easily-overlooked/
Mark,
Although I appreciate your vitriol, your claims are so far outside the realm of accepted knowledge on the subject it is becoming laughable to many. I am never against “a new way to skin a cat” and general ideas but these articles you are presenting show nothing new and only cause further confusion.
Once the research in this “vestibular trauma event” stuff catches up; which in my opinion is not even close. We can discuss it again.
I will ask you kindly to stop posting about this information here, going forward, I believe it to be a veiled attempt at garnering publicity for your products.
As a quick reminder – NO MOUTH GUARD or DEVICE has proven to attenuate concussion or even vestibular events? Especially since vestibular events involve floating crystals, how would anything in your mouth prevent that?
OK, I am done and because this is my blog I will have the final say on this, for now.
df
you have not any idea what CTE iis like i went thru the initial stages of anger and depression and now find myself in the fourth stage ; mermory loss and depression; i had 6 concussionns in tht CFL and have lost everything important to me; mostly my wife i wish i had never played.
that was not meant for you dustin as i know you are doing all to help ex players like me; it was a statement to all the peoplle who watch the game and do not see what goes on off camera
floating crystals= Pixie dust, what ever you say Dustin. Really, are you also now getting a check from the NFL. Sensoring NIH research, ASS
Mark,
Again, what you present is not research: a link to a non-biased webpage. The Bangor Daily news article references a UPMC study focused on vestibulo-oculomotor reflex dysfunction – which is a very well known entity. However, there is nothing about TMJ or physio-postural status in that article. It doesn’t support your contention that “50% of all these reported events are of vestibular nature” either. These are concussions, and yes, some have VOR dysfunction.
Also, in your first comment, you had referenced the traumatic vestibular events could be shaken off in your first comment — the UPMC study that you just attempted to reference to support your argument directly contradicts that. These athletes cannot shake it off, they are being seen in clinics while still symptomatic.
It certainly does appear that you are trying to push some type of product or therapy.
Mark,
No more, please. And thank you.
I love the “concussion like symptoms” statement… what a farce!!
That statement refers to what the sideline reporters say following a player getting a concussion… it’s a joke
Arguments aside… San Diego is also the former home of the late Junior Seau, who shot himself in the chest, allowing his brain to be studied for CTE – it was there. And eight of the players from the 1994 Chargers squad have died prematurely since that time, all by the age of 44. See the list here: http://en.wikipedia.org/wiki/1994_San_Diego_Chargers_season#Deaths_of_players
This cavalier treatment of concussion appears to be a cultural one.
In San Diego, as well as generally.
Great article—this whole site is such a valuable resource. I had a concussion last year, and I’ll never forget, three days after the concussion when I finally got to the ER based on the symptoms that kept increasing, the ER doctor told me I could go back to teaching Spin…the next day. Thankfully, we looked into other opinions, as I still was only just getting back to almost-100% teaching levels two months later. I can’t believe how many professionals are still so uneducated about the implications of a concussion. Thank you for spreading this information. I am sharing on Twitter now…
You should watch browns chargers 2016. Addae hit first quarter real good then in for second quarter.