A Semi-Annual Publication of the Professional Football Athletic Trainers Society • Summer 2003 • Vol. 21, No. 1
Management of a Cerebral and Spinal Cord Concussion
in a Professional Football Player
Ryan Grove, MS, ATC, Ariko Iso, MA, ATC, more familiar to most athletic trainers.
John Norwig, MEd, ATC, Joseph Maroon, MD
n Cerebral concussion: This is an electro-
A thletic injuries usually do not result in
catastrophic and irreversible damage.
However, the potential for such an
injury, especially when it involves the head or
chemical phenomenon triggered by a
traumatic or violent blow to the head.
Although there is generally no structural
damage to the brain, a cerebral concus-
neck, is a major concern for those who care for sion results from the disruption in the
athletes participating in collision sports. A chemical and electrical activity in the
brain or spinal cord injury can cause brain. Specifically caused by the release of
permanent paralysis and athletic trainers potassium and other ions into nerve
must be prepared to recognize, evaluate and synapses, this interruption is commonly
manage an athlete with this type of injury. referred to as being “knocked out,” and
The purpose of this article is to present a case can result in loss of consciousness, confu- Tommy Maddox is knocked unconscious.
study in which a professional football player sion or disorientation.
suffered both a spinal cord and cerebral to the right. This resulted in the anterior
n Spinal cord concussion: Although ex-
concussion during competitive play. aspect of his head and helmet being driven
tremely rare, this is analogous to a cerebral into the playing surface.
Epidemiology concussion in that a violent impact to the
Head and neck injuries tend to be associated spinal column causes function of the spinal On-Field Management
with organized sports, specifically football, cord to shut down due to the electrochemi- As we approached Maddox, he was motion-
wrestling or gymnastics. But in reality, these cal imbalances. However, instead of losing less and lying face down, so we:
types of injuries are more common in recre- consciousness, there is a transient loss of all 1. Immediately focused on stabilizing his
ational activities such as swimming, diving or spinal cord functions with no structural head and neck with manual fixation as a
playing on a trampoline.1 Studies show that damage to the cord itself.3 cervical spine fracture or spinal cord injury
10 percent of all sports-related spinal injuries should always be suspected in an uncon-
occurred from diving accidents, while only scious athlete.
The injury occurred on November 17, 2002,
three percent resulted from participating in 2. Performed a primary survey to assess his
in the third quarter of an away game against
organized sports.1 level of consciousness, checking his airway,
the Tennessee Titans. Pittsburgh Steelers
Head and neck injuries associated with respiratory and circulatory systems. He was
Quarterback Tommy Maddox was running to
football have decreased dramatically at all unconscious and unresponsive, but we
his left when he was tackled by an opposing
levels since 1975, even though the number of could tell that he was breathing as his thorax
player. As he was falling, he received a severe
participants continues to increase.2 Although was rising and falling.
blow to his left shoulder and cervical spine
the incidence is decreasing, several recent 3. Executed a log-roll maneuver to place him
area by a second defensive player. It is believed
high-profile cases in the NFL have shown that in a supine position, allowing for a more
that this blow caused immediate unconscious-
these types of injuries can still occur. thorough assessment of his condition. We
ness and loss of sensory and motor function
Cerebral vs. Spinal Cord in all four of his extremities. continued to stabilize his head and neck with
Cerebral concussions occur more frequently The collision also caused the quarter- manual in-line stabilization and slight
than spinal cord concussions and may be back’s head to slightly flex forward and rotate traction. His helmet was left on with the
Continued on Page 3
IN THIS ISSUE:
Page PFATS President Page Gatorade Sports Science Page A roundtable discussion:
Steve Antonopulos Institute creates a Tips and techniques from
2 announces new
PFATS Web site
4 unique hydration system
6 five NFL athletic trainers
News and Notes Message From the President
Brian Magat joins the
Cleveland Browns as
an assistant athletic
trainer. Brian earned
T he goal of our organization has
always been to provide the best
health care for our athletes and the
entire NFL community at large. We are also
PFATS web site. The
first version of www.
PFATS.com will launch
near the beginning of
his undergraduate dedicated to finding new ways to meet our the NFL season in
degree from the members’ needs, as evidenced by our September. While we’re
University of Illinois recent strategic planning session in still working out the
at Chicago and his Chicago. We evaluated the status of our specific content, rest Steve Antonopulos
graduate degree from Brian Magat organization and discussed ways to make assured it will reflect well on our profes-
the University of Nevada-Las Vegas.He worked our membership even stronger than it sion and provide us with efficient and
for the Browns as a training camp intern in is already. effective ways to stay connected and
2001 and a season long intern in 2002. We also worked with our partners at updated on the issues and practices that
Jeff Otte becomes The Gatorade Company to brainstorm impact us. I am very excited about this
the newest member of ideas for joint projects. I am very pleased new endeavor and hope you’ll share in my
the Minnesota Vikings to announce that we are creating a excitement once the site is operational.
medical staff. He joins
the organization as PFATS Members Meet to Chart NFL Athletic Training Staff of
an assistant athletic Association’s Future the Year
trainer after working Eight PFATS members gathered this past Head Athletic Trainer Jim Maurer and
as an intern with the March in Chicago for a two-day meeting to Assistant Athletic Trainers Britt Brown and
team during the 2001 review and revise the organization’s mission Greg Gaither of the Dallas Cowboys have been
and 2002 seasons. He Jeff Otte and long term strategic plan. Current PFATS named the 2002 NFL Athletic Training Staff
received his graduate degree from Indiana President Steve Antonopulos (Denver of the Year. They became the 18th staff to be
State University and did his undergraduate Broncos) and Immediate Past President recognized by their peers in receiving this
work at Gustavus Adolphus College in Ronnie Barnes (New York Giants) oversaw prestigious award.
Minnesota. the meeting, during which the group
Reggie Scott was conducted various exercises to examine
named as an assistant the issues, changing dynamics and increas-
athletic trainer with ing demands PFATS members face in the
the Carolina Panthers. NFL today.
Reggie, who graduated “I think it’s essential and extremely valu-
from the University of able to take time away from the training room
West Virginia, spent to really examine the state of our association,”
2002 as a year long said Antonopulos. Knowing where we are
intern with the Tampa will help us articulate where we think we
Bay Buccaneers. Reggie Scott can, and should, go next.”
In addition to Antonopulos and Barnes,
Award Winners other PFATS members in attendance included 2002 NFL Athletic Training Staff of the Year
The following awards were handed out at the Brad Brown (Tennessee Titans), James Left to right: Greg Gaither, Jim Maurer and
2003 NFL Combine: Britt Brown of the Dallas Cowboys
Collins (San Diego Chargers), Troy Maurer
n The Cain Fain Memorial Award was (Miami Dolphins), Sam Ramsden (Seattle
presented to Ronnie Barnes, New York Seahawks), Bill Tessendorf (Baltimore
Giants’ head athletic trainer and former Ravens) and Ryan Vermillion (Carolina Pro Football Athletic Trainer
The Semi-Annual Publication of the
PFATS president. This award is sponsored Panthers). Professional Football Athletic Trainers Society
by the NFL Team Physicians Society and Summer 2003 Vol. 21, No. 1
presented to the PFATS member who Editorial Advisors: Todd Lazenby, ATC, San Francisco 49ers
best reflects the virtues of a certified John Norwig, ATC, Pittsburgh Steelers
Joe Recknagel, ATC, Detroit Lions
athletic trainer and the highest level Scott Trulock, MA, ATC, Tampa Bay Buccaneers
of professionalism. Managing Editor: Miles Rush, MS, ATC, CSCS
Editor: Lorri Christou
n The Jerry Rhea “Hawk”Award was given Direct Inquiries to: Miles Rush, MS, ATC, CSCS
to Art Rettig, team physician for the 875 North Michigan Avenue, Suite 3300
Indianapolis Colts. It is sponsored by Chicago, IL 60611
PFATS and presented to the NFL team 312.751.3733
doctor who has made the greatest Left to Right: New York Giants’ Head The PFATS Newsletter is made possible through the courtesy of
Athletic Trainer Ronnie Barnes, PFATS The Gatorade Company (1-800-88GATOR, www.gatorade.com).
contributions to both the NFL and the President Steve Antonopulos and
The Gatorade Sports Science Institute Web Site can be accessed
profession of athletic training. Indianapolis Colts’ Team Physician Art Retting
Management of a Cerebral and Spinal Cord Concussion in a Professional Football Player
Continued from Page 1
chinstrap fastened for additional stabili- extremities following the injury was due to Rehab and Return to Play
zation. Although he was still unconscious, an electrochemical abnormality and not a Our first goal was to make sure Maddox had
his respirations and pulse were normal. structural disruption of the cord. a full understanding of his injury and the
He regained consciousness after several possible risks associated with participating
minutes. CT Scan and X-Rays in football. With the help of diagnostic
Doctors ordered a CT scan to identify any studies and our team neurosurgeon, he was
4. Had the team physician then perform a sec-
cervical spine abnormalities that may not have given the information needed to make a
ondary survey, assessing his level of con-
been apparent on the MRI. They also reviewed decision about returning to professional
sciousness, cranial nerve, motor and
plain X-Rays. Results from both tests showed football. Once he decided to stay in the sport,
sensory functions, and learning as much
no sign of fracture or dislocation. it became our responsibility to make sure
information about the injury as possible.
From the neurological exam, he determined Diagnosis he was mentally and physically ready.
the athlete had motor and sensory loss in As a result of the on-field and clinical test- Since his MRI, CT scans and ImPACT
all four extremities and the potential for a ing, Maddox was diagnosed as having test results were normal, we addressed his
cervical spine fracture. suffered both a cerebral and spinal cord subjective complaints by emphasizing a
5. Placed Maddox on a spine board using a concussion. Diagnosis of a cerebral concus- gradual progression to full activity based
half log-roll maneuver. Once secured to sion was based on: on complete symptomatic relief. To help him
the board, he was lifted onto on a stretcher n Loss of consciousness for at least two
recover mentally and physically from the
via a six-person lift and positioned feet initial trauma and intensive care treatment,
first into the ambulance to prevent axial we instructed him to rest and perform
n Concurrent retrograde amnesia for approxi-
loading from deceleration and braking simple activities of daily living until he felt
mately 30 minutes. asymptomatic.
during transport to the hospital. Even
The spinal cord concussion was identi- Once asymptomatic at rest, he began a
though the athlete’s respiratory status
fied by: functional progression of exercise consisting
was normal, we followed our standard
n The athlete’s inability to feel and move his of light nonsport-specific aerobic activities
operating procedures and removed his
face mask with a power screwdriver prior arms and legs for approximately 30 minutes (e.g., riding a stationary bike) and a few
to transport to the hospital. following the injury. sport-specific activities (e.g., throwing a
n The fact that the MRIs, CT scans and football).
Diagnostic Testing X-Rays revealed no anatomical, physiologi- We monitored his symptoms using a
Upon arriving at Baptist Hospital in Nashville, cal or structural damage to the spinal cord visual analog scale and additional ImPACT
clinicians immediately performed: or spinal column. testing. He also increased his mental
n An MRI of the brain and spinal cord functioning by participating in off-field
Follow-Up Care activities such as watching film, team
n A CT scan of the cervical spine
Maddox was transferred back to Pittsburgh meetings and interacting with players
n X-rays of the cervical spine
the next day where the Steelers’ Team and coaches.
Cervical Spine MRI Neurosurgeon Joseph Maroon performed The emphasis of his rehabilitation
Three primary reasons for the cervical spine a complete physical and neurological exam program then moved to position-specific
MRI are to: and administered the Immediate Post drills. Restrictions on team activities were
n Rule out a fracture or dislocation and deter-
Concussion Assessment and Cognitive Test removed as soon as he felt comfortable.
(ImPACT).4 ImPACT is a computer-based By carefully increasing the time, type (non-
mine the existence of herniated discs.
testing method used to establish normative contact vs. limited contact vs. full contact)
n Identify any bruising, contusions, hemor-
values for an athlete’s subjective complaints and intensity of sports-related activities,
rhaging or swelling to or in the spinal cord. and cognitive functions including reaction Maddox was able to return to practice.
n Determine the existence of spinal stenosis, time, memory, orientation and processing He returned to full competition once he
as there are significant implications regard- speed of the brain. was asymptomatic at rest, with exertion and
ing further participation in collision sports Maddox first took a baseline exam in with contact.
if the spinal canal is narrowed, even if there August 2001. These results were then com- Neurocognitive function and Maddox’s
is complete return of function. pared to the findings from his retest the day report of symptoms were closely monitored
The cervical spine MRI study showed after the injury. The post-injury test noted during the entire rehabilitation process.
no evidence of fractures, dislocations, mild declines in memory and reaction time
herniated discs, hemorrhaging, spinal but indicated his acute neurocognitive Conclusion
stenosis or any intrinsic abnormalities recovery was excellent. Cervical spine injuries can be devastating for
within the spinal cord. He was re-evaluated two days later and the athlete, the athlete’s family and those who
results showed continued improvement with care for him. When a neurological injury
Cerebral MRI occurs, it is the responsibility of the sports
memory and reaction time. Overall, his brain
Doctors ordered an MRI to identify any brain medicine team to rapidly assess the scene,
function had returned to a normal state
injury. As no abnormalities to the brain or immobilize the head and neck and prepare the
within 48 hours of a significant blow to the
spinal cord could be identified, they deter- athlete for transport to a trauma center where
head and neck.
mined the athlete’s loss of function in all four Continued on Page 8
News From GSSI
Fueling More than Race Cars
Jeff Zachwieja, PhD n Be light weight, the majority which is from
Matt Kenseth, who has won the most races of the fluid itself
any NASCAR driver this year, knows some- n Deliver fluid easily
thing about dehydration and the importance n Be hands-free
of fueling himself to stay safe while making n Hold enough fluid to last an entire race
hundreds of laps around the racetrack. For
Kenseth, and the other NASCAR drivers, a day Gatorade In-Car Drinking System
of competition means racing at about 185 After several months of prototype develop-
miles an hour for up to three hours at a time ment, driver feedback, fabrication and even
— and in a car that can heat up to 130°F. crash testing, the Gatorade In-Car Drinking
Add to that the impact of wearing a full-body System (G.I.D.S.) was born. The system,
fire retardant suit and helmet, and Kenseth which once sealed can be mounted just
The Gatorade In-Car Drinking System
easily qualifies for athlete status. Not unlike about anywhere in the car, consists of:
football players in full uniform during two-a- attached straw under their helmets or through n An insulated, protective pouch made of
day workouts, he and the other drivers really their face shields to drink.It was a cumbersome Kevlar material that resists conductive and
need to beat the heat during extreme hot process for such a high-tech sport. radiant heat.
and sweaty circumstances. n A flexible reservoir holding up to 100 ounces
GSSI Helps Drivers Drink
of fluid that is inserted into the Kevlar pouch
Sweating It Out During a Race Not surprisingly, the combination of high along with freezer gel packs to maintain a
Knowing the challenges NASCAR drivers face in-car temperatures and poor accessibility to consistently cold (45°F) fluid temperature.
in managing heat-related issues of safety and drinkable fluid led to the observed dehy- The fluid reservoir is connected to a
performance, scientists from the Gatorade dration. As is the case with other athletes, a battery-operated pump. When a switch acti-
Sports Science Institute (GSSI) set out to help dehydrated driver will heat up more quickly, vates the pump, it circulates cold fluid
address the problem in 2001.The first step was and this can impair both physical and mental through an insulated delivery tube. This tube
to collect data on drivers’ sweat rates and fluid performance. Most important for NASCAR connects to a small mouthpiece on the inside
intake during a NASCAR Winston Cup series drivers, dehydration will: of the driver’s helmet. To drink, the driver
race. To our knowledge, this was the first time n Slow reaction time
simply bites down on the mouthpiece without
anyone had studied the hydration needs of the n Reduce hand-eye coordination having to take his or her hands off the steer-
most skilled drivers in stock car racing. n Impair cognitive functioning ing wheel or gearshift.
What did we learn? Through research and discussions with
n Drivers were well hydrated before the race
Use and Reaction
drivers, crew chiefs and their teams, we began Two drivers used a G.I.D.S. prototype during
n Drivers lost one to two quarts of sweat per to understand just how challenging it is to get the final six races of the 2002 season. Six
hour of racing drivers the fluid they need during a race. We drivers then used G.I.D.S. during this year’s
n Fluid intake did not match sweat loss also realized doing so was paramount for the Daytona 500. Because reaction to the system
n Drivers were almost two percent dehydrated health and safety of the drivers. With this in has been so positive by drivers and pit crew
by the end of the race mind, GSSI scientists and engineers at the members,it’s expected that many more drivers
Most remarkable were the limited opportu- Quaker Oats Company Research and Develop- will use it during summer races when temper-
nities to drink and the manner in which drink- ment Center committed to creating an in-car atures and humidity soar.
ing was accomplished. During pit stops (lasting hydration system for NASCAR drivers. “Since we first started testing the system
only 13 to 15 seconds), crews passed drink Together, we established that this unique with Matt last year, we noticed that he is drink-
bottles to the drivers. The bottles contained delivery system should: ing more fluid during a race,” said Todd
mostly ice and drivers had to maneuver the n Keep fluid cold throughout a race
Millard, crew specialist for Matt Kenseth’s
No. 17 Roush Racing Team.“G.I.D.S. also helps
2003 GSSI Conference: Hot Topics in Sports Nutrition make Matt’s pit stops more productive. Instead
of having to hand Matt a sports bottle, we are
The 17th annual GSSI conference is scheduled for July 24-25, 2003, at the Downtown Marriott able to utilize our time in other ways to help
Hotel in Chicago.Whether you’re a certified athletic trainer or a student who’s interested in him win.”
sports nutrition, the conference promises to deliver. Researchers and practitioners from At GSSI, we believe that G.I.D.S. will set
around the world will explore the effects of creatine, protein, amino acids, supplements, the standard by which NASCAR drivers
antioxidants and caffeine on the athlete’s system. They’ll also address how to curb muscle achieve optimal hydration for their sport.
cramps, improve immune function and enhance recovery. We invite you to be a part of it.
For more information and to register for the conference, go to www.gssiweb.com. Jeff Zachwieja is a senior scientist at the
Gatorade Sports Science Institute.
Inter-Association Task Force on Exertional Heat Illnesses
Douglas Casa, PhD, ATC, FACSM dration. Replacing lost sodium after exercise is Treatment • Aggressive and immediate whole-
I n February 2003, more than 20 medical best achieved by consuming food in combina- body cooling via cold water immersion is the
experts from 18 professional associations† tion with a rehydration beverage. key to optimizing treatment of EHS and
came together in Atlanta to form an inter- Return to Play • Continued participation is should be initiated within minutes post-
association task force on the prevention,recog- acceptable if dehydration is minor and the incident.
nition and treatment of exertional heat athlete is symptom free. Periodic checks from n Immediately immerse athlete in tub of
illnesses (EHI). The group’s mission was to on-site medical personnel are recommended. cold water (approximately 35°-58°F/1.67°-
develop guidelines to increase safety and per- Heat Exhaustion 14.5°C), onsite if possible. Remove clothing/
formance for people engaged in physical activ- Heat exhaustion results from strenuous physi- equipment.
ity.Following are excerpts from that statement. cal exercise and environmental heat stress. It n If immersion is not possible, transport
Preventing EHI can be recognized in an athlete who has diffi- immediately. Alternative cooling strategies
Every athletic organization should have a plan culty continuing intense exercise in heat, mild should be implemented while waiting for
for addressing exertional heat illnesses and the hyperthermia (usually <104°F/40°C) and a and during transport.These strategies could
key factors to identify the early stages of an lack of severe CNS dysfunction. include spraying the body with cold water,
exertional heat illness. These include: Other possible symptoms include dizzi- fans,ice bags or ice over as much of the body
n Intrinsic factors such as inadequate heat ness, dehydration, profuse sweating, headache, as possible and/or cold towels (replace
acclimatization, lower levels of fitness cramps, etc.* towels frequently).
Treatment • It’s best to remove athletes from n Monitor airway, breathing, circulation, core
status, dehydration, etc.*
n Extrinsic factors such as prolonged exercise activity to a shaded or air-conditioned area temperature and CNS status
and remove excess clothing and equipment. n Place an intravenous line using normal
with few breaks, exposure to high tempera-
tures, limited access to fluids, etc.* Then: saline (if medical staff is available)
It’s possible to reduce the risk of exertional n Cool athletes until rectal temperature is n Cease aggressive cooling when core temper-
heat illnesses through an implemented heat approximately 101°F (38.3°C) and lay them ature reaches ~101°-102°F (38.3°-38.9°C)
illness education program and by providing comfortably with legs propped above heart n Transport athlete to medical facility
appropriate onsite medical staff. This staff level Return to Play • Physician clearance is neces-
should perform preparticipation physical n If not nauseated, vomiting or experiencing sary before returning to exercise.
examinations that address fluid intake, weight any central nervous system (CNS) dysfunc- *For more information on exertional hypo-
fluctuations, medication and supplement tion, rehydrate athletes orally. If athletes natremia, heat cramps, exertional heat illness
use and history of cramping or heat illness on can’t take oral fluids,implement intravenous or to read the entire consensus statement, see
all athletes. normal saline the June edition of the NATA News or visit
n Monitor heart rate, blood pressure, respira- www.nata.org.
When athletes do not replenish fluids, they tory rate, core temperature and CNS status
n Transport to an emergency facility if rapid Douglas Casa is the director of the athletic training
become dehydrated. Mild dehydration (less
improvement is not noted education program at the University of Connecticut.
than two percent body weight loss) is often
unavoidable because athletes cannot always Return to Play • Athletes should be symptom †The Inter-Association Task Force
balance fluid intake with fluid losses. Even free, fully hydrated and cleared by a physician
on Exertional Heat Illnesses
mild dehydration can hinder performance and before returning to play. American Academy of Pediatrics
thermoregulatory function. Exertional Heat Stroke (EHS) American College of Emergency Physicians
Symptoms may include dry mouth, American College of Sports Medicine
Exertional heat stroke is a severe illness char- American Dietetic Association
thirst, irritability, apathy, decreased per- acterized by CNS abnormalities and potential American Medical Society for Sports Medicine
formance, etc.* tissue damage resulting from elevated body American Orthopaedic Society for Sports Medicine
Prevention • Maintaining normal hydration temperatures. American Osteopathic Association of
(as indicated by baseline body weight) is the Recognition • The ability to rapidly and accu- Sports Medicine
key to avoiding heat illnesses. Athletes should American Physiological Society
rately assess core body temperature via rectal CDC – Nutrition and Physical Activity
not be allowed to practice if their total body thermometer and CNS functioning is critical Department of Defense Health Affairs
weight loss is greater than two percent of their for evaluating EHS. Most critical are: Gatorade Sports Science Institute
baseline. They should: n CNS dysfunction (altered consciousness, National Association of EMS Physicians
n Begin each exercise session properly hydrated North American Society for Pediatric Exercise
coma, convulsions, disorientation, irra-
n Have convenient access to fluids during tional behavior, decreased mental acuity, National Association of Sport and Physical
practice and in addition to prescribed irritability).* Education/AAHPERD
breaks n Hyperthermic (rectal temperature usually National Athletic Trainers’ Association
Treatment • The athlete should first be moved >104°F/40°C) immediately post-incident National SAFE KIDS Campaign
to a cool environment and rehydrated with a National Strength and Conditioning Association
Other symptoms may include nausea, U.S.Army Center for Health Promotion and
sports drink containing carbohydrates and dizziness, hot and wet or dry skin, increased Preventative Medicine
electrolytes (e.g., sodium and potassium). heart or respiratory rate, etc.*
Flavoring may also enhance voluntary rehy- 5
A ROUNDTABLE DISCUSSION:
Tips and Techniques From the NFL Sidelines
Geoffrey Kaplan, ATC, Assistant Athletic Trainer, Dave Kendall: I’m impressed because even Kendall: My three favorites are hands, sports
after all my years in the league, I carry those cord and surgical tubing.We are also fortunate
Dave Kendall, ATC, Head Athletic Trainer,
Kansas City Chiefs same four things, Geoff. I also carry a mirror to have an aquatic unit, which allows us do a
Jim Maurer, ATC, Head Athletic Trainer, in case there’s a problem with contact lenses. myriad of exercises whether it be nonweight
Dallas Cowboys Nasal plugs as well. bearing, partial-weight bearing, upper
Jeff Tanaka, ATC, Assistant Athletic Trainer,
San Francisco 49ers Jim Maurer: I actually don’t wear a fanny extremity or lower extremity.
Todd Toriscelli, MEd, ATC, Head Athletic Trainer, pack at practices, since there are athletic train- Rush: Moving away from the topic of rehabil-
Tampa Bay Buccaneers ing kits set up at each of our water pumpers itation, what is the strangest injury you’ve seen
Miles Rush, MS, ATC, CSCS, discussion moderater
and all the equipment I need is near by. while working in the NFL?
Additional editorial assistance for this article was
provided by Magie Lacambra, Med, ATC, Skeeter However, I do tend to carry tongue forceps,
Schuessler, Todd Sperber, MA, ATC and Jason Wulf, an oral screw, half-inch tape gauze and Band-
ATC, CSCS. Aids for that quick repair.
The job of an athletic trainer in the NFL may Todd Toriscelli: The one thing I do a little
seem exciting and glamorous, but at its most differently is carry a Palm Pilot. There’s
basic, it is still about taking care of the health always something that comes up, maybe the
and safety of athletes. We sat down with five coach and I have a conversation about an
athletic trainers with more than 60 years of event or an injury occurs that I want to
collective NFL experience to learn a little about document, and I can write it in my Palm Pilot
their jobs and some of the wisdom they’ve for future reference. It also contains every-
acquired from their careers on the sidelines. body’s phone number.
Miles Rush: What’s the most important item Rush: Interesting. Can you identify your three
you carry in your fanny pack and why? favorite pieces of rehabilitation equipment? Todd Toriscelli, Tampa Bay Bucaneers’ head
Jeff Tanaka: I was going to say I carry a Toriscelli: I frequently use a piece of equip-
Sharpie pen, but even though we had nothing ment called the Shuttle, which is basically a Kaplan: I’ve seen a few. The first was a
to do with it, I’ve already taken enough heat horizontal leg press device with bands that can stroke suffered a few years ago by a rookie
about that! be used for added resistance. I like it because offensive lineman. He complained of tingling
it’s very specific based on what angle you want and numbness on one side of his face and
your athlete to work at. You can really isolate down through his arm during practice, so
parts of the range of motion that are pain-free, we held him out of activity to see if it
which is a big confidence builder. would resolve. It didn’t, so we had him
Tanaka: A couple of our favorite pieces are evaluated immediately by our team internist
physio balls and medicine balls. Physio balls and they diagnosed him as having a cerebral
are extremely versatile, you can use them to vascular accident or stroke. Very unusual for
train both the core and the extremities, and a 22-year-old male.
medicine balls are great for changing resist- Rush: Any idea what caused it?
ance and the athlete’s center of gravity. Kaplan: Not really. He was African
Kaplan: I agree, Jeff. In fact, I use something American, had borderline hypertension, high
called a Bosu, which is basically a physio ball cholesterol and his family history wasn’t
cut in half and mounted on a platform. It’s good. While those are all big risk factors
about half the size of a 55 cm physio ball, and I for an older person, he was still very young
love it because it’s low-tech and cheap.You can for having a stroke.
Left: Jeff Tanaka, San Francisco 49ers’ use it either right-side up or right-side down
assistant athletic trainer Rush: So what ended up happening?
and it helps build both upper and lower body
Kaplan: He was put on injured reserve and
(All): Laughter balance and proprioception. Another piece of
unfortunately his football career ended. I don’t
Tanaka: The most important things I carry equipment I use is my hands. There’s huge
think there was a doctor willing to clear him
are personal protective items, such as gloves value in being able to put our hands on our
and no one was willing to take the risk.
and a CPR barrier. I also carry a digital tape- athletes and do different exercises, whether it
be stabilization exercises or strengthening Rush: What was the second injury?
less recorder to take notes if anything happens
on the field. exercises. This is something we can’t get away Kaplan: The second was an axillary vein
from and I think we all enjoy doing. thrombosis that happened to one of our defen-
Geoffrey Kaplan: In no specific order of
Maurer: Yes, our hands are indeed critical sive backs. He came in after practice and one
importance, I carry a CPR barrier mask, a face
pieces of equipment. And to that extent, so are arm was three times bigger than his other arm.
mask extractor, a single-dose epinephrine pen
our heads in thinking of new exercises for our Veins just popping up and sticking out, it was
and a cell phone. All are important, as you can
athletes. Another thing we find very effective really incredible. He went into the hospital and
potentially have a catastrophic event without
is a biofeedback unit, especially with lower the doctors removed his first rib and anticoag-
any one of them.
body injuries in the first phases of rehab. ulated him, and he was back on the field six
weeks later.We really aren’t sure what caused it, feeling really bad and he could hardly walk.
but it was strange to see. So, naturally we got him in the ambulance
Kendall: One that sticks out for me hap- and to the hospital and they started working
pened to one of my players while he was on him to see what was wrong.
rehabbing an ACL reconstruction. This was Rush: What did they come up with?
early in my career, back when this procedure Maurer: They performed a variety of tests,
was done with an open incision. During one of but the results all came back negative. He
our rehab sessions, he started complaining of wasn’t getting any better, so they decided that
chest pain.We had our doctors look at him and they would have to perform surgery to find out
they diagnosed him with a life-threatening what happened. During the surgery, they
blood clot caused by the surgery. It really discovered that the force of the blow had
caught me off-guard as I had never been pushed his intestines against his spine, com- Center: Geoffrey Kaplan, Tennessee Titans’
exposed to something like that — and it pletely severing his jejunum. Our internal assistant athletic trainer
taught me not to take subtle things for granted. medicine physician said he had never seen about the hydration patterns and sweat rates of
Tanaka: That’s very true, Dave.When I was in anything like it before. some of our problem players, and we were able
college and working with a men’s basketball Rush: How did the injury resolve? to address these problems. We also make sure
team, we had a player get some dental work our athletes stay healthy the old-fashioned way,
Maurer: He was in the hospital for about two
done and it ended up getting infected while we by having them weigh in and weigh out before
months but he had a full recovery. After he
were on the road. We sent him to the doctor and after every practice to make sure they are
came back to us, we put him through an
as soon as we could but the infection went replacing the fluid they lose through sweat.
extensive rehabilitation program and he was
systemic. He ended up spiking a fever and Tanaka: Educating the coaches is important
actually able to play a little that next year.
being rushed to the hospital. The whole side as well. Making sure they understand how
of his face and neck was swollen and they Toriscelli: A similar injury happened to one
of my players when I was a head athletic important hydration is and what’s going on
ended up having to extract the tooth. I hadn’t with our athletes is key. It gets the coaches’
really thought that something that starts out trainer in college. The athlete was struck in
the abdomen on kickoff but didn’t even get attention when we tell them that the guys will
relatively benign, like dental work, could perform better when they are well hydrated.
become so serious. the wind knocked out of him. He came
off the field on his own and sat on the bench. We’re fortunate because our head coach really
Maurer: We had a wide receiver who took is good about working with us and listening
Even though he said he was fine, I knew he
a helmet right to the middle of his gut a to what we have to say. He supports us and
was hurt. He seemed to be coming around but
few years ago. You knew it was a bad hit, he gives us the time to meet with the players.
within five minutes his condition started
lost his breath and was on the ground Kaplan: As athletic trainers, we’re always
going downhill. He had tremendous groin
for awhile and even though he never lost preaching to our players to drink fluids, but
pain, looked pale and his pulse was very
consciousness, he was definitely hit hard. we’re starting to be more specific in terms of
rapid. So we sent him by ambulance to the
After a few minutes, we got him to the side- what they drink — and prefer they have sports
hospital and it turned out his spleen had
line, and he said that he was starting to feel drinks over water. That’s because we’ve had
been ruptured. Interesting that his groin pain
better, although he still felt a little sick. Well, guys drink a lot of water and still cramp up
was probably caused by the blood running
about five minutes later he said that he was very badly. Some of these guys will grab big
down into his lower abdomen.
Rush: Over the past few years, the topics of one gallon jugs of water and chug them all day.
heat illness and hydration have become widely But since they’re not replacing the sodium they
discussed within the athletic environment. lose in sweat, they still cramp and wonder why.
How do you make sure your athletes stay prop- Rush: It’s clear you guys play an important
erly hydrated during practices and games? role on the field, just by virtue of making these
Kendall: We do as much as we can to educate recommendations. That said, would you
our players as soon as possible on the subject. recommend a career in the NFL to a newly
Ten-year veterans and rookies, alike, we don’t certified athletic trainer who is not sure about
wait until training camp to preach to these where to work?
guys about hydration and heat illness. We Maurer: I truly enjoy being an athletic
start talking hydration as soon as they sign trainer and I must admit that the nostalgia
with our team. of being part of the NFL is a lure for me.
Toriscelli: I agree that education is critical. I love being a part of the Dallas Cowboys,
We’ve had scientists from the Gatorade Sports and it’s a very good fit for me. Many of our
Science Institute (GSSI) come in and present to student athletic trainers have told me,
our team on hydration and nutrition. The GSSI “I can’t wait to start my career in the NFL
scientists even came to our facility to study because I want to try to get your job,” which
some of our athletes who had a history of I think is great because I’ve exposed them to
Jim Maurer, Dallas Cowboys’ head athletic cramping and other dehydration-related prob- a career they want to pursue. I also feel good
trainer lems. I learned a great deal from the scientists Continued on Page 8
A ROUNDTABLE DISCUSSION
Continued from Page 7 Cerebral and
when other students realize that the NFL
Spinal Cord Concussion …
Continued from Page 3
may not be the best work setting for them.
Tanaka: We get athletic training students all further treatment and diagnosis can be
the time who write letters or apply for intern- achieved.It is essential that the sports med-
ships and say, “My goal is to work in the icine team take every caution necessary
NFL,” and I always want to ask “Why?” What when evaluating, treating and managing
they see on television may look glamorous, the athlete to prevent further damage.
but there’s a lot more to the job than Sundays.
Ironically, I never had the goal of working Right: Dave Kendall, Kansas City Chiefs’ head John Norwig is the head athletic trainer and
in the NFL. I just wanted to be good enough athletic trainer Ryan Grove and Ariko Iso are assistant
to have a job as an athletic trainer some- athletic trainers with the Pittsburgh Steelers.
important to students, then they’ll ultimately Joseph Maroon is a team physician for
where. I was fortunate enough to get some become frustrated and fail.
opportunities in, and exposure to the NFL, the Steelers.
and I found that was the direction I wanted Kendall: It doesn’t happen very often, but Photo Credit: Pittsburgh Steelers/Mike Fabus
my career to go in. every now and then I’m reminded of why I do
this. I’ll be on the sideline on a game day and References
Kaplan: I’d tell new ATCs that if they want to one of my players, who I’ve done a lot of work 1 Bailes, J. Management of Cervical Spine
be in the NFL, they can’t be in it just for the with, will nudge me or put his arm around me Sports Injuries. Athletic Training 25(2), 156-
Sundays. Game days and working with high 59, 1990.
and say,“You know what? You did a hell of a job
level athletes are the best part of the job, 2 Mueller, F. Fatalities From Head and Cervical
and I appreciate what you did for me and Spine Injuries Occurring in Tackle Football:
but the novelty of working in the NFL wears thank you.” There’s not any amount of money 50 Years’ Experience. Clinics in Sports
off quickly if they’re not willing to work the or glory that can replace that feeling. Medicine 17(1), 99-110, 1998.
other 350 odd days when there aren’t games. 3 Zwimpfer, T, Bernstein, M. Spinal Cord
If you’re not in if for the right reasons, you’ll Geoffrey Kaplan, who received the 2000 NFL Concussion. Journal of Neurosurgery 72, 894-
start asking yourself “Why am I spending so Athletic Training Staff of the Year Award, has 900, 1990.
much time away from my family, why am I spent nine years as an assistant athletic trainer 4 Maroon, J, Lovell, M, Collins, M, Bost, J. The
working 85 hours a week and spending 17 with the Tennessee Titans. Dave Kendall, who is Evaluation of Athletes with Cerebral Concus-
hours in the training room and on the sideline sion. Clinical Neurosurgery 49, 319-332, 2001.
only the second head athletic trainer in Kansas
each game day for 16 Sundays?” Winning on City Chiefs history, has worked as an athletic Recommended Reading
game days is the goal, but if you’re not disci- trainer in the NFL for 29 years. Jim Maurer has Kleiner, D, Almquist, J, Bailes, J, Burruss, P,
plined and focused, you’re going to have a hard Feuer, H, Griffin L, Herring, S, McAdam C,
earned three Super Bowl rings during his 14 Thorson D, Watkins R, Weinstei, S. Prehospital
time being an athletic trainer in the NFL. years with the Dallas Cowboys, the last eight as Care of the Spine-Injured Athlete: A Document
Toriscelli: NFL football is the greatest game the team’s head athletic trainer. Jeff Tanaka has from the Inter-Association Task Force For
on the planet played by the greatest athletes been an assistant athletic trainer with the San Appropriate Care of the Spine-Injured Athlete.
in the world, and just to be a part of it is a Francisco 49ers for five years. Todd Toriscelli has Dallas, Texas, National Athletic Trainers’
privilege. It’s easy to say you want to be in the been the Tampa Bay Buccaneers’ head athletic Association, March 2001. This document can
NFL because of what it is to the public eye, trainer for seven years and won his first Super be located at www.nata.org.
but you have to love being an athletic trainer Bowl championship in 2002.
first. I get a lot of satisfaction out of helping Photo of Todd Toriscelli: Tom Wagner/Tampa Bay
people reach their goals, and if that’s not Buccaneers
Atlanta, GA 30361
P.O. Box 386
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