Case Study: Multiple Concussions in a Division One Soccer Athlete

Amanda M. Langton, MEd, ATC, NREMT-I

University of Georgia

Personal Data

•22yo WF SOC Mid-Fielder•Height: 5’4”•Weight: 141 pounds•Transferred after freshman

year from another Div. One University

•Family history of migraines

Medical History• Claims 3 headaches per week since ’99,

generalized in nature• Migraines (Imitrex, 50 mg)• C5/C6 Pedicle Fx./Vascular Groove• Oligomenorrhea• Fractured R. Upper Molar/false tooth

10/00• L. Ankle Grade 2 Lateral Sprain 9/02• R. Knee Grade 2 MCL Sprain 9/99• R. Dislocated Shoulder 10/99• L. Wrist Fracture 11/98

Concussion History• 4 Concussions

Prep Years• 2 Syncopal

Episodes • 2 Grade II

Concussions (AAN)• 1 Grade III

Concussions (AAN)

Prep Years• 4 concussions prior to collegiate career

(Youth-High School), no documentation- Denies losing consciousness with any-Concussion (1997) at Soccer Camp, collided with another player’s head, while attempting to head the ball, on that occasion she indicated she lost partial vision of her left eye for one day and had reports of nausea and dizziness lasting about 5 days. One week out symptom free. Returned to px. the next week and completed high school/club career with out any further episodes (2 years).

Freshman Year 2000• Documented Syncopal Episode

during two-a-days with an exertional fitness test

• LOC for +/- 30 seconds• Nausea• Vomit x4• Headache• Dizziness• RTP within the week

Sophomore Year (2001)

• 9/9/01, UGA vs. UCONN -MOI: At. collided with another players elbow in the Left Temporal/Occipital Region during a corner kick-Assisted off the field-Unable to balance, confused, dazed-Foggy on events from trauma (anterograde),

vaguely recalls flying home-Headache, Vomit x3-No LOC-Examined by UCONN Team Dr. -CT Scan (Normal)-Tylenol

UGA vs. UCONN (Cont’d.)• Self-reported symptoms improved dramatically

same day & At. flew home• Neurocom & Neuropsych, 9/10/01

-72/80 self-reported symptoms compared to only 6 at baseline (no Vomit)-Improved with each trial, whereas with such high self-reported symptoms she should have worsened-Reaction times slowed, balance lower than baseline-At. committed 34 errors on Neuropsych (normal 10-12)

• It was decided At. was purposely doing poorly on the testing (possibly milking the injury, scared, etc.), but that she would be treated according to self-reported symptoms

UGA vs. UCONN (Cont’d.)

• Post Concussion -4 days post felt in a fog, no headache reported, difficulty sleeping-one week later felt great, began jogging, abs, stationary soccer drills-2 weeks later returned to full soccer training

• At. was fitted for a mouth guard to be worn at all practices and games

• 9/21/01 – Returned to full game participation

Sophomore Year (2001) • 11/18/01, UGA vs. UF

-MOI: At. went up for a header and feet were knocked out from under her & she landed on the small of her back and buttocks, then falling backwards with her head hyper extended hit her occiput on the ground, 30 seconds previously she had been struck in the head with an elbow and appeared (by teammate and ATC account to be dazed)

-LOC for 10-15 seconds-Prone no movement, awoke w/sternal rub, not alert

or oriented, ABC’s intact-C-Spine was controlled, At. had tenderness on C-

spine and upper back, no palpable deformity-Decreased motor & sensory ability on R. Arm &

Leg-911, C-Collar, board, Vitals were stable,

transported via ambulance to UF Shands ER

UGA vs. UF Hospital Care (2001)

• Evaluated at ER• CT Scan (Brain & C-Spine)

-Brain (normal)-Neck (non-displaced C5 pedicle fracture)

• MRI C-Spine (normal)• Solumedrol Bolus, then drip• Weakness on R. side subsided after 2.5 hours,

returned to 5/5 Bilaterally• Some retrograde and mild anterograde amnesia• No headache, but given her R. sided weakness and

C5 fracture she was kept overnight for observation, then released in an Aspen Collar and pain meds

UGA vs. UF (Cont’d)• Follow-up Care w/Dr. Dix, Neurosurgeon

-Evaluation (Pain in Neck remains, denies numbness, tingling, good conversation)-It was decided she had a Grade III Closed Head Injury with contusion to left motor strip resulting in R. Side symptomology-Interpretation of CT Scan by Dr. Val Phillips, it was decided that the fx. was actually a vascular groove (abnormal blood vessel)-Remain in Rigid Collar for at least 6 weeks-Flexion/Extension X-rays once pain has subsided (they were normal 12/5/01)

Grade III Concussion/Cervical Pathology Follow-Up

• 12/01 - D/C collar, AROM

• 1/14/02 – Cont. AROM, light cardio, neuro intact, slight pain w/lateral flexion & rotation to the left, increase in right side symptoms with impact (run or jump)

• 1/29/02 – follow-up scheduled w/Neurosurgeon

Sophomore Year (2002)• Syncopal Episode w/combination of light jogging

(cleared to do) and pulling of tire (not cleared to do)

• Reports nausea in am prior to running, poor diet Dizziness, then LOC 30 sec, awoke with contact from ATC – alert and oriented

• Headache post episode, neuro intact, no additional symptoms reported – was seen by physician assistant the same day

• Ordered MRI w/o contrast (brain pathology), 2D echocardiogram (cardiac function), nutrition consult

• Keep appt. w/Neurosurgeon next week to discuss results and future participation in soccer

• No physical exertion at this time

Syncopal Episode (Cont’d.)

• MRI was WNL• 2D Echo was WNL• Nutrition Appt. • 1/29/02 – At. re-check

with neuro, cleared from a c-spine position, but recommended D/C soccer for the year. Her present status was discussed with her parents.

• Discuss D/C soccer permanently.

Sophomore Year 2002

• At. Cont. to exercise independent of team practice with sporadic complaints of headaches

• 3/02 - Began non-contact soccer drills• 5/02 – At. Requested appt. to discuss RTP

decisions, the negatives were discussed at this time and At. was told one additional concussion within the calendar year would hold her from soccer for 1 year – at the end of the summer, prior to 2-a-days beginning a meeting was set (athlete, parents, coach, & medical staff)

Junior Year 2002• No contact soccer since 11/01• Home (New Jersey) for the summer, reports no neck

or syncopal symptoms, a couple of migraines (Imitrex controls them)

• Meeting (At., mother, coach, PA & ATC) – all parties were given the opportunity to speak – Decision At. Could participate, as long as headaches did not worsen and the first concussive or syncopal episode would result in termination of the season, no repetitive heading drills

• Gradual progression into heading drills, mouth guard• Headminder and Neurocom were repeated for new

baselines, WNL (except for a slight reduction in simple and complex reaction times – which was attributed to her past concussive history)

Junior Year 2002

• No reported or observed incidents, Fall of 2002

• At. Cont. to take Imitrex to control Migraines

• 4/5/03, At. contacts the ground when her legs are taken out from under her and face plants into the ground

• She is immediately removed from the game

Junior Year 2003

• At. is obviously apprehensive about sharing symptoms, but understands her coach and myself were aware an incident had occurred

• At. Complains of headache, nausea, dizziness, feeling unsteady, light sensitive

• She can explain in detail the incident and answers all memory and intelligence questions with ease

• At. is done for the day and with only 1 week to go in spring season, she is restricted to progression to non-contact fitness

Junior Year 2003 (Cont’d.)

• 3 Days post incident, balance testing WNL, Neurocognitive - decreased simple and complex reaction times, self-reported symptoms were elevated from baseline

• Day 10 (4/15/03) – balance testing WNL, self-reported symptoms remain elevated (headache, fatigue, neck pain and drowsiness, but intensity has decreased) NC – Complex reaction times were WNL, simple remain greater than baseline indicating a decrease in Neurocognitive performance.

Grade II Concussion Follow-UP

• 4/15/03 – Appt. w/team PA, Neuro intact, normal appetite, no nausea or vomit, sleep has improved but is restless at times, concentration is better in class and on studies, balance WNL – Grade II (AAN)

• Concerns over slowed resolution of symptoms, with a 3rd concussion in a 2 year period – our index of concern is raised

• Cont. Tylenol as needed, no exertional activity• Discussion with mother and coach over best

interest of At. & RTP decisions• 5/03 – At. went home for the beginning of the

summer, symptoms have resolved. She and her mother are to have a discussion concerning their and our concerns for At. to RTP

Summer 2003• After much discussion amongst our medical staff

and the desire of At. to RTP it was decided to have a consultation with an expert in closed head injury, Dr. Robert Cantu was consulted and an appointment was scheduled for 7/10/03.

• Dr. Cantu was sent all relevant diagnostic reports (films, disks, & reports), Neurocom & Headminder, as well as Physician notes and a detailed documentation of all reported concussive and syncopal episodes, these records along with his physical exam would be an additional opinion to help the At. & her family understand the risks involved in cont’d participation in the sport of soccer and her future of the field

Dr. Cantu’s Report

• Neurological Exam – several mental status tests of months repeated backwards, 6 numbers forward and backward and independent objects were all perfectly carried out by At.

• Cranial testing as well as reflex, motor and detail balance testing all proved WNL

• Headminder CRI reports from April were reviewed and he decided that with normal retest of the CRI he “would have no absolute contraindication to this young lady returning to soccer.”

Senior Year 2003• After deliberation between Andrea, her mother and

UGA medical staff it was decided Andrea would be allowed to participate in soccer for her senior campaign with the same specification as her Junior Fall, even one concussion or syncopal episode and her season would be terminated

• Andrea completed her Senior Season with no reported or observed incidents

Exit Physical

• At. still reports at least 3 headaches per week, migraines are limited to only a couple per year

• Still has neck pain with and post intense physical activity, C-Spine MR shows normal alignment, no cord abnormality, no nerve root impingement & no evidence of a fx.

• She continues to play soccer recreationally

Concerns• Return-to-play decisions are always difficult,

especially in the face of pressure from uninformed coaches, athletes or parents. Early return of an athlete to play when the brain needs a longer time to recover is an enormous concern.

• The lack of consensus on this subject makes the clinician's role even more challenging. There are over 16 different guidelines for the evaluation of concussion. However, by focusing on the areas in which the different guidelines agree rather than those in which they differ, the clinician can feel prepared for most scenarios.

• Another serious issue is the cumulative effects of repeat concussions – how will these closed head injuries affect the At. long term?

Concussions do not all appear alike. There is no consistent set of symptoms, and there is no one formula to treat every patient. That is why it is critical to treat each patient on a case by case basis, utilizing all testing at your disposal and taking a complete and thorough medical history.