The brain game in youth football

Concussions represent a hot topic, but coaches, leagues and others are making safety a top priority


Will Smith starred in a movie about it.

The NFL is expected to pay $1 billion because of it.

The NCAA, several universities and even Pop Warner programs are being sued over it.

The dreaded concussion and the possible long-term effects it can have on football players – at any level – represent a major concern and the subject of countless debates over whether enough is being done to protect players.

For thousands of kids across the country, youth football provides the chance to be a part of a team, to emulate their sports heroes and to play America’s favorite game. But reports of players suffering lifelong problems, the astonishing rate of CTE (Chronic Traumatic Encephalopathy) cases in pro athletes and the rash of recent lawsuits have made some weary about allowing their kids to play football, while others believe the recent exposure of concussion effects have made the sport safer and those leading it more educated.

So how much risk is there really? And is it worth the reward?

Local youth league coaches and leaders feel good about the changes that have been made.

 Scott Haak, director of coaching and player safety for the Junior Development League of Ponte Vedra, believes the pros of playing youth football far outweigh the cons.

He said, at least in the Junior Development League of Ponte Vedra, safety is a priority.

“There are so many great things kids learn from football,” said Haak, who has been a physical therapist at the Mayo Clinic for 17 years and also specializes in sports medicine.

One of the measures Haak said the JDL teaches to reduce the number of head injuries is the shoulder-tackling model, rather than hitting with the head. They spend much of their time learning “on air,” he said, by going through the motions with footwork and technique, participating in no more than 30 minutes of live contact. Haak said working on hand placement, resistance and learning proper technique makes up the majority of practice and better prepares kids to play at a higher level.

“JDL is engineered to be about the kids,” Haak said.

Kids in the league play at every position and are matched up based on ability rather than other factors, like size. Haak said in his four years of coaching in the league, he had only one reported concussion on his team. He attributes the low number of head injuries in the JDL to training and education of the coaches and the diligence the JDL has in assessing possible injuries.

In the JDL, Haak explained that players are given baseline testing to assess their brain function, and any possible head injury is immediately assessed through the baseline test as well as other tests and dealt with quickly.

“If in doubt, pull them out,” Haak said.

The majority of head injuries, he continued, result from improper tackling, especially when it comes to skill players, and proper technique is the best way to prepare kids for future football careers.

“The biggest concern is tackling” he said. “It’s much better to start in a developmental program. We work a lot on the fundamentals of blocking and tackling.”

He also said unlike some other youth football programs in the nation, which has seen a decline in participation because of the fear of concussions, the JDL hasn’t faced a drop-off.

“The parents that bring kids out to play don’t seem to have reservations,” Haak said. “Maybe because they trust us.”

But for many youth football players, the most important part of playing is just having fun.

“We put kids having fun and safety above winning,” Haak said. “Adult competition is not what we do. The reason kids play sports is to have fun.”

 Forward progress

Eric Henkel, former commissioner of the JDL in Ponte Vedra and member of the Ponte Vedra Palm Valley Athletic Association (PVAA) football board for 12 years, said during his time in the area youth league, safety was a focus early on.

The JDL and PVAA leagues follow the “Heads Up” Initiative from USA Football, which promotes safety first and a focus on fundamentals.

“We have seen a decline,” Henkel said of concussions in youth programs he’s been involved with. “The JDL and PVAA were on the forefront of USA Football’s 'Heads Up' Initiative.”

For Henkel, knowledge is key, particularly for coaches and parents.

“Coaches, team moms know how to fit the equipment properly and be aware of signs of any head injury,” he said.

Henkel said the local youth programs have made significant investments in safety, including better equipment and training for coaches, including “teaching coaches different techniques to ensure heads are protected at all times.”

“All of us are on the same page to make sure we’re making this game as safe as possible,” Henkel said.

He believes the safety protocols area youth leagues have in place have instilled confidence in parents who may have had doubts about letting their children play youth football.

“Participation has grown over the last couple of years,” Henkel said. “We’ve been good at communicating what we’re doing and how we’re doing it.”

 Protecting players

Throughout the state of Florida, youth football players had an ally in government in 2012 when it came to concussion safety, thanks to a bill that was passed making medical scrutiny more stringent and requiring better training for coaches, schools and leagues.

Former State Rep. Ronald Renuart of Ponte Vedra spearheaded the legislation and Gov. Rick Scott signed the bill into law on Oct. 12, 2012 at Ponte Vedra High School. The law expanded on rules set by the Florida High School Athletic Association (FHSAA) to include youth leagues and sports clubs.

Renuart, who is a physician with Baptist Medical Center, said he was proud of the efforts made in legislature through the bill and believes coaching has changed for the better in the years since the bill became law.

“What it’s actually shown is the sports community, at the high school and middle school level, is that education about concussions has grown considerably,” he said.

Renuart said that education is critical and must extend beyond just having better equipment.

“There has to be proper coaching,” he said. “You want to look to have kids participate in a program that has formal training in safety measures.”

Despite the growing controversy over concussions in football, Renuart believes kids shouldn’t be scared off from competing.

 “Participating in sports is part of the growing process,” he said. “We just want it to be as safe as possible.”

Renuart pointed out that the biggest problem regarding head injuries was players returning before they were completely healed and suffering another hit to the head, which causes the most lasting damage to the brain, especially in a young person whose brain is not fully developed. That’s why, he said, a combination of better equipment, specialized training and how injuries are handled is so important.

“We don’t want to ruin their opportunities at a young age,” Renuart said.

 A parent’s dilemma

For many parents, though, it can be a tough call to allow a child to play tackle football, especially when they don’t always know what and how techniques are being taught.

Cle Cooks’ 11-year old son plays flag football, and Cooks isn’t particularly interested in seeing him make the move to tackle football any time soon.

“My son Michael has played flag football for the last six years, and he loves it,” said Cooks, a Jacksonville resident. “He never really expressed an interest in playing tackle, which we were fine with. Partially because of the concussion risks and my doubts about some coaches at that level caring about what's best for my child and his health over winning games.”

Cooks said Michael did suffer a concussion, however, but from a fall at school and not on the football field. But because of the injury, Cooks is even more wary of letting Michael play tackle football.

“Now that he already has a concussion history, I don't think it would be prudent for us to allow him to play tackle until he is older and has had significant time to heal from the trauma,” Cooks said.

Cooks isn’t completely closed to letting Michael play at a higher level if he chooses, but would definitely want to know what techniques are being used to prepare him.

Cooks said trust in coaches and leagues is definitely an important factor in allowing your kid to play youth football, but agrees that enjoyment is also a top priority.

“I want him to play for the love of the game and to have fun,” Cooks said. “I don't have to worry about playing for a scholarship or trying to get into the NFL. If he eventually decides that is what he wants, then we can have that conversation and find a team and coaches that I trust, but until then, he can learn the fundamentals while playing flag football. He won't know how to take a hit until then, but we have time for that.”

Cooks also acknowledges that not every kid in youth leagues will keep playing, and not every future NFL star competed in tackle football in their youth.

“It's not for every kid, and there have been plenty of players who didn't play a down of football until high school,” he said. “And why do the damage to their bodies at that age, if you don't have to?”

For some parents, the idea of not playing is worse.

For example, Haak isn’t just a youth football coach and physical therapist. He’s also the father of a youth football player and believes the benefits outweigh the concerns, especially given the current focus on safety and technique. He says better health, building confidence and learning teamwork are just some of the benefits of youth football.

“The risk of not playing is much higher than the risk of playing,” Haak said.


Q&A with Atlas Physical Therapy & Sports Medicine


Employees from Atlas Physical Therapy, with two offices in St. Augustine and one in Jacksonville, answer questions about sports-related concussions:

Adam Schoenberg MPT, ATC, LAT; licensed physical therapist and certified and licensed athletic trainer.


Jordan Monroe ATC, LAT; certified athletic trainer. Atlas liason to Nease HS sports medicine.


Have you seen an increase/decrease in the number of concussions involving young athletes, particularly football players?

Schoenberg: The most cited value for sports and recreation-related concussions (SRCCs) is 1.6 to 3.8 million incidents each year in the U.S. This was taken from a 2006 article in the Journal of Head Trauma Rehabilitation. A more recent study was published in the Journal of the American Academy of Pediatrics that estimates 1.1 to 1.9 million SRCCs each year. This may appear as a decrease, but the likely explanation is improved reporting that has seen a better assessment and measure of true SRCC.


Monroe: Anecdotal evidence suggests a decrease in the number of concussions associated with high school football players; however, there was no change, if not an increase, in concussions amongst middle school-aged football players. This could be attributed to a number of things, including better understanding and education of concussions amongst high-school level coaches, as well as athletes and parents, sports medicine staff availability, proper equipment fitting, and improvement in skills, including tackling and hitting.

 Have you noticed more concussions in football players than those involved in other sports? What is the most common injury seen in young football players?

Schoenberg: American football remains one of the most prevalent sports in the U.S. for SRCCs; however, a study performed in a British journal that looked at worldwide sports saw rugby and hockey as more prevalent for SRCCs.

Monroe: Anecdotally... yes. Due to the repetitive nature of football and high frequency contact associated with the sport, concussions are more commonly seen amongst these athletes than any others. Football players not only risk suffering a concussion from impact with another player. They're also susceptible to receiving a concussion when their head hits the ground. All contact sports predispose an athlete to increased risk of concussion because the number of mechanisms for injury are greater.

From Monroe’s personal experience, “I would have to say shoulder injuries. Year after year we see our fair share of dislocations and subluxations, labrum tears, and rotator cuff injuries. The shoulder is the most mobile joint in the human body and when you have an increase in mobility, you have a decrease in stability. This predisposes the shoulder to injury most of all.”

 How long should a person diagnosed with a concussion refrain from physical activity? Would the timeframe be longer for football?

We follow the guidelines set forth by the Florida High School Athletic Association


1.      The first criteria before returning to any exertional activity is that the individual

must be symptom-free and cleared as such by an M.D. or D.O.

2.      Once they are determined to be symptom-free they will begin a graded, five-phase

return to play protocol. The individual must pass all five phases of the protocol

without symptom aggravation during or 24 hours after each phase.

3.      Once they have passed the five-phase test and are cleared by a M.D. or D.O., who

may request additional testing/imaging, then they may return to sport. There are no differences in return to play for football players versus other sports. Testing and criteria is specific to the individual.

 Does Atlas use any different or unique techniques to treat concussions? What role does physical therapy play in the treatment of concussions?

Atlas is unique in that we have all of the tools to treat concussed individuals outside of physician-ordered imaging. We have physical therapists trained in vertigo assessment and treatment and athletic trainers who are well-versed on the return to play criteria and process and can be onsite with the athlete as they resume their sport.

Our team of physical therapists and athletic trainers work with a large population of athletes and we have the means to replicate their sport within our facility or by going out to the field.

Additionally we offer a concussion management program in which we provide baseline testing for individuals who are not offered this by their school or association. We are able to keep those records and should the individual suffer a concussion, we a have a baseline neuropsychological test to compare to.

Concussion symptoms

·         Headache, dizziness, loss of consciousness, amnesia, “pressure in head,” confusion, memory difficulties, balance and coordination deficits, lightheadedness, ringing in ears (tinnitus), changes in personality, vertigo, sleep disturbances, fatigue, nausea/vomiting, light sensitivity, fatigue/drowsiness and personality change.

·         Associated symptoms commonly seen from head/neck trauma but not directly related to concussion: neck pain, back pain, shoulder pain, swelling and bruising.



·         Self reporting measures relying on questions and answers administered by a

healthcare provider looks at accuracy of response and quality of response.

·         Neuropsychological measures such as impact testing or vital signs uses a

standardized test to measure an individual's post-concussion scores against pre-concussion testing baselines or database norms.

·         Medical imaging.


·         First and foremost is to refrain from any activity that may put the individual at risk for an additional concussion

·         Rest and avoidance of overly stimulating activities including school, video games and electronic devices

·         Physical therapy for associated musculoskeletal complaints, vertigo, balance and coordination deficits


Provided by Atlas Physical Therapy & Sports Medicine