Coach Steve: Lessons to learn after suffering a concussion

Z Marquis had just turned 18. He was playing for a club soccer team known as FC Arizona and had gotten scouted by a local community college coach. He wanted to play the sport beyond college.

He still has those aspirations, but his career has been on hold since he collided with a teammate in a game at a Las Vegas tournament. For a year and a half, he has continued to sustain the lingering, debilitating effects of the concussion that followed.

“It’s kind of been making me lose a bit of hope,” he tells USA TODAY Sports.

He was trying to take the ball from an opponent during the March 2022 game. He remembers, at the same moment, one of his teammates attempting to shoulder check the player, who moved out of the way and avoided the hit. Marquis absorbed it.

“I got like really bad whiplash,” he says. “I got really nauseous, really dizzy, things started changing colors, a bunch of stuff like that. … I was just dazed there for a couple of seconds.”

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He stayed in the game. Before you judge him, consider the Tua Tagovailoa episode in the NFL from last September. The Miami Dolphins quarterback appeared dazed, too, when a Buffalo Bills player pushed him on his back and his head hit the turf. He even fell over while jogging back to the huddle, though he attributed the fall to a back injury. After a brief absence and undergoing concussion protocol, Tagovailoa was back in the game, too.

Marquis didn’t even fall, and he didn’t hit his head.

“It was complicated,” he says. “I remember somebody else getting injured and we were already playing a game a man down with no subs, so after I got hit, I like recuperated for a second and we only had like five minutes in the half.”

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At halftime, after he described to his coach how he was feeling, the coach told him to sit out. Marquis played four games a couple of weeks later but has mostly rested ever since. Tagovailoa, who endured a second scary episode after he was allowed to play four days later and had his head slammed to the turf by a Cincinnati Bengals player, has also rested and been given a clean bill of health to start the new NFL season next Sunday.

Marquis is in limbo.

“I can’t play competitively with my current symptoms at all,” he says. “I can’t push myself enough to get into shape to where I can play at a competitive level, so I’ve been mainly focusing on just trying to figure out what’s wrong with me and how to fix it before I’m looking back into actually trying to play competitively again.”

This is a story of what can happen when an amateur player trying to make it to the next level sustains a concussion, thinks he is taking the right steps and can’t quite turn the corner, at least not yet. The story offers lessons of not only how you have to immediately heed the warning signs of a concussion but also how tough it is to fight off the urge to keep playing, a narrative we also saw play out with Tagovailoa last season.

“This one is a very telling story about how dangerous concussions are,” says Zack Kampf, Marquis’ coach at Chandler-Gilbert Community College in Arizona. “I’ve had moments in my life where teammates played through getting hit pretty hard. Looking back at it, it probably was a concussion but they didn’t have those very clear symptoms where, like, ‘Oh, I don’t feel good, oh, I’m gonna throw up, oh, I feel dizzy.’ It was just, ‘Oh man, that hurt.’ ”

Not living in real time

Marquis says he felt completely fine after resting following the game in which he got hit, well enough to play in four more games that season. He took about two weeks off and played in another tournament. The tournament turned out to be a grind. One of FC Arizona’s main defenders got a red card that had the team down a player. Marquis’ endurance was poor. He felt a little dazed after two games in which he headed the ball.

“But I was so focused on the game that I didn’t think much of it,” he says.

And when he would rest, he felt normal.

“My parents were talking about it, and they were like, ‘As long as you feel fine, then we probably don’t have to worry about anything' ’cause usually you get some sort of symptom fairly recent to getting a concussion,” he says.

Marquis rested for a couple of months before he started training for his first season with Kampf at Chandler-Gilbert. He hadn’t seen anyone about his issues because he felt fine at rest. But when he exerted himself physically, the bad nausea and dizziness returned and he had had blurry vision. His head pounded and he couldn’t focus.  

During summer meetings with the coaching staff, Marquis mentioned his symptoms to Kampf. Kampf gave an assistant coach at knowing look.

“You should probably get that checked out,” Kampf told Marquis.

It was a concussion, confirmed when Marquis had an MRI of his brain. He redshirted the season and saw a series of doctors and a vestibular therapist, who explained how what his brain was processing and what he was seeing weren’t necessarily connected.  

“I was basically living in the past technically,” he says. “What I was seeing wasn’t in real time. It was, like, a split second behind what I would have actually been seeing, so if somebody passes me the ball and I go to receive it, what I’m actually trying to receive has already passed what I was thinking I was going to be seeing.

“Let’s say I’m running past a pole and as soon I’m like directly in line with it, that’s current time; but my brain wasn’t processing it in current time. When I was at that point, my brain would be a split second behind so I’m not necessarily seeing where I was at that time. My brain was processing that I was like half a step behind when I was really in line with the pole.

“It wasn’t like a big gap where I’m like seconds behind. It was just like a very little kind of jump between where I was and what I was seeing.”

During his vestibular therapy, he underwent a series of concussion tests to challenge how fast and accurately his brain could function. The tests ultimately corrected his brain lag. He looked at a red square in a blue circle and pressed a key regarding which one popped up. He looked at a dot and shook his head side to side as fast as he could while keeping his eyes directly on it. (He did this stationary and while he was walking.) He laid down on his bed with his feet on the floor and, then rolled to his left side, laid flat, sat up straight and rolled to his right, moving his body and head quickly.

He was cleared, he says, after his scores improved from about 25% of normal performance to the upper end of the 95 percentile for his age group. He also got  checked out by a cardiologist to make sure his symptoms weren’t related to his heart and was told he was perfectly healthy for his age. But his wearying symptoms persisted with exercise.

“I thought I was cleared and my problems would go away but they didn’t,” says Marquis, now 19. “If I do participate in something, I can’t go 100%. I can’t get better unless I’m giving it everything I have.”

Symptoms can linger

Tagovailoa admits the concussion process “took forever.” After he was knocked unconscious against the Bengals, the NFL even modified the protocol. The league determined any player showing signs of ataxia – where an abnormality of balance/stability, motor coordination or dysfunctional speech is caused by a neurological issue – is prohibited from returning to a game.

He wound up sitting out a playoff game and hasn’t played in a regular-season NFL game since Dec. 25.

It’s not completely out of the ordinary for Marquis to still be out, too. A friend of mine who is a neurologist in Northern Virginia said she has seen some cases of concussion where there is a post-concussive syndrome that lasts 1 to 2 years. Usually this occurs with more severe injuries like a car accident, she says, but it can rarely happen in sports. 

Marquis planned to see a neurologist next, a step for which she emphasizes the importance if there isn’t the expected improvement in several months. Sometimes my friend also orders a cervical spine MRI to rule out a disc bulge and an electroencephalogram (EEG) to rule out seizures and might try a medication similar to what is used for migraines. 

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How Z's story can help you

Playing right after his injury, she says, risked a second injury, which would have caused an even more serious situation. If you are an athlete of any age, make sure you are following your league’s concussion policy. My local youth leagues have leaned on the Positive Coaching Alliance. Kampf, who overseas more than 100 kids from ages 7 to 22 in his coaching endeavors, uses the HEADS UP concussion training program.

“Whenever I lose a player from concussion, I always turn to my assistant coach and I’m like, ‘Well, we’re not gonna have him for two weeks.’ And that’s how it always turns out.”

While football and hockey have higher rates of concussions, soccer generally ranks third among youth sports in frequency. High school numbers compiled from the 2021-22 school year show there were more than 55,000 concussions diagnosed among boys and girls soccer players.

Headers aren’t permitted by US Youth Soccer at age 10 or under. Kampf says the youngest player he has had with a concussion was at age 14, when a boy got hit pretty hard on the side of the head. Kampf took him out, though the player said he was OK. Kampf had him checked by a trainer.

The boy’s mom called me the next day and said he had a concussion.

“He felt perfectly fine but it was like four hours later that he was throwing up at his house,” Kampf says. “That’s when it started to kick in. That’s something that they do teach in the concussion courses is that the symptoms and signs, they don’t always show right away. Sometimes it’ll be a few hours and you can make him a lot worse if you go and do something while they seem normal.”

Important questions to answer

I submitted some concussion questions to JustAnswer pediatrician Dr. Denise Scott. Here are her responses:

How do you define a concussion?

A concussion is an injury to the brain from a hit to the head which causes the brain to move in the skull. A concussion does not require loss of consciousness. This can occur as a result of a fall, vehicle accident, sports, or an attack. (Editor’s note: Remember, though, in Marquis’ case, he wasn’t hit in the head and still sustained a concussion.)

How are concussions different in youth (school-aged) athletes than they are in grown-up (college and pro) athletes?

Since the brains of children and adolescents are still developing, they tend to be at higher risks for effects. For one, the skull is larger compared to the brain and the neck muscles are weaker than an adult’s allowing for more movement of the brain inside the skull. With that additional space, brain injury can occur with greater acceleration, potentially leading to more nerve injury. The safety equipment used by younger athletes are not going to be as protective as those used by professional athletes. 

Because of the developing brain, children may have more symptoms after a concussion and take longer to recover from the injury. 

What is your experience with treating concussions in youth sports?

As a pediatrician, pediatric endocrinologist, and founder of a pediatric urgent care clinic, I have seen my share of concussions. The recommendations for treatment have evolved over time. Initially, there weren’t specific guidelines and we recommended the child abstain from sports until symptom-free and rest for 2-3 days. We would evaluate the patient to determine whether an imaging study (CT scan) should be done to rule out any bleeding. 

Later, the recommendation was for the youth to completely rest the brain for two weeks which meant no physical activity, computer work, video games, television, etc. We would write letters to the school so that they would allow the student to be relieved of tests and homework. As you can imagine, adolescents went stir crazy and rarely fully complied.

Current management includes restricting physical and cognitive activity for at least 24-48 hours followed by light, physical, non-contact activity (such as walking) rather than strict physical rest. Early, low levels of exercise are safe, and mentally and emotionally beneficial. If this exacerbates symptoms, then they should refrain for another day or two. They must refrain from any activity that has risk for another head injury (such as biking).

Similar restrictions are for cognitive activity - complete brain rest for 24 to 48 hours then limited activity such as limited homework or watching limited television. Once a patient feels that they can concentrate for at least 30 to 45 minutes without symptoms, they can return to school, with possible academic adjustments, and as tolerated. 

During this time, they should have weekly follow-up with their provider who will determine return to play. This is a gradual participation, first with non-contact exercises that then increase in intensity over time. For full participation, they need to be back in school full-time, be symptom free off medication, and have a normal neurologic exam.

What are the most common signs or symptoms of a concussion in a young athlete?

The most common signs of concussion include physical, cognitive, emotional, and sleep-related symptoms. The symptoms seen the most are physical and include headache, nausea, with or without vomiting, neck pain, and light sensitivity. 

Additional symptoms that are often seen include difficulty concentrating, fatigue, sleep disturbances, and irritability.

Traumatic brain injury can also affect the endocrine system. This is not common but I have seen some patients for this concern and had a patient with no pituitary function after a motor vehicle accident.

What is your recommended protocol once you see these symptoms?

I follow the American Academy of Pediatrics (AAP) guidelines. I first do a physical and neurologic exam, followed by a discussion with the patient and family outlining the treatment. I recommend full rest of the body and brain for 2-3 days with instructions to call for any worsening symptoms and define concerning symptoms. This is followed by light activity with a follow-up visit in a week, at which time I outline the plan for further activity based on their symptoms.

What is the range of time a child must sit out from sports after suffering a concussion?

There is no hard and fast rule since every case is different. The return to full participation is gradual, with steps outlined previously. The child needs to be completely symptom free with a minimum time of five days. The goal is to prevent recurrent injury.

What is the biggest mistake you have found in how adults, especially coaches, treat concussions in youth sports?

I think that this has also evolved and now, because of increased awareness of the consequences, adults are less likely to encourage a player to “shake it off” and convince them to return to play. With so much research available, coaches are trained better and held accountable. There will always be some who are more focused on winning, but I think that many have more concern for their player’s well-being. In fact, it is sometimes the coach who insists that a player be evaluated.

The biggest mistake is allowing a player to return too quickly and not recognizing the signs of concussion.

What are some concussion-related incidents you have watched that have been handled properly that can help young athletes?

I have seen patients who were sent in by their coach which I was very happy about. I did have one patient who was a daredevil - participated in rodeo sports, motocross, and football. By his third concussion, I told him and his parents he should take up tennis or golf!

Steve Borelli, aka Coach Steve, has been an editor and writer with USA TODAY since 1999. He spent 10 years coaching his two sons’ baseball and basketball teams. He and his wife, Colleen, are now loving life as sports parents for a high schooler and middle schooler. For his past columns, click here.

Got a question for Coach Steve you want answered in a future column? Email him at [email protected]