The NFL's concussion conundrum

Notwithstanding Robert Griffin III's scintillating play on Sunday, his return from a "mild concussion" within a week of its occurrence -- and the continued absence of the Lions' Jahvid Best a year after his last concussion -- shines a spotlight on the issue in the NFL.

As the league gathered this week in Chicago, there might be no issue more important to the NFL's past, present and future than that of concussions and head injuries.

The "concussion conundrum," as I call it, puts the league at a crossroads, now playing out against a backdrop of hundreds of lawsuits from thousands of plaintiffs suing the NFL for negligence, fraud and concealment. This is not only a football issue; it is a medical issue and, unfortunately for the NFL, a legal one as well.

Culture change

A tipping point came during 2009 congressional hearings on the topic. NFL commissioner Roger Goodell and NFLPA head DeMaurice Smith were taken to task about a perceived apathy and callous attitude. Rep. Linda Sanchez even compared the NFL to (gasp!) the tobacco industry. The hearings jump-started a positive trajectory of new measures in the NFL.

Soon after those hearings, the Mild Traumatic Brain Injury (MTBI) Committee -- established in 1994 under former Commissioner Tagliabue -- was revamped. The co-chairs of the previous committee, Dr. Ira Casson and Dr. David Viano, resigned under pressure after repeatedly denying a causal link between playing football and future brain injury. (The MTBI committee is mentioned prominently in the concussion lawsuits.) At the time, Goodell said he wanted to add new members "who will bring to the committee independent sources of expertise and experience in the field of head injuries."

In October 2010, after a weekend that saw Rutgers player Eric LeGrand paralyzed and several vicious collisions in the NFL, the league stepped up its enforcement of violent hits. It has also adopted increased player safety mechanisms, including independent neurologists to clear concussed players for return, and on-field trainers, who have no past affiliation to the team, to monitor game-day head trauma. And the new CBA mandates players receiving extensive time away in the offseason and far less contact in practice when there.

A player once "dinged" is now "concussed." Batteries of tests performed by doctors on the sidelines have replaced smelling salts and ammonia tablets. The NFL -- with the threat of significant fines -- is challenging the Redskins' initial in-game injury report on Griffin of "shaken up." Concussions and brain injuries have become part of the NFL lexicon in ways not anticipated years ago.

The positive arc of concussion awareness and treatment bodes well for the present and future but underscores what was being done -- or not being done -- in the past. As noted above, the past, more than the present, is the focus of the concussion lawsuits.

What to do

In football, we are used to dealing with knees, shoulders, ankles, hamstrings and others and we know protocol on return to play for each. These protocols do not work with the head.

While some doctors would clear a player after symptoms subside for the week following a concussion, others would mandate at least a week off before returning to play, despite passing all tests. When I asked one respected neurologist what he would advise a parent about when his son should return to play after a concussion, his answer was: "Fifty years." No one truly knows.

Is it OK for Griffin to return to play a week after being concussed? On the anniversary of his last concussion, Best, who has had multiple concussions, is still not cleared to play today. The independent neurologists working with the Redskins cleared Griffin a few days after a concussion. Would all independent doctors around the NFL agree with that assessment? That is debatable.

The continuing hope is that any decision on return to play after a concussion is made with complete independence from the team's football operations. Players need to be protected, and due to the stark business reality of the NFL, they often fail to protect themselves.

Keeping their jobs

The advent of cognitive baseline testing such as the imPACT test, which began a decade ago, has been a constructive and necessary step. Taken prior to the season, the test establishes a normal threshold for the player's cognitive function used to guide the medical staff in similar testing when a player is concussed. In theory, this works well.

Many players -- more than we would like to believe -- intentionally "flunk" the initial test to not appear concussed when tested later after a head injury. The reason, of course, is simple: job security.

Players are not concerned with health risks 20 years from now. They are worried about the next play, the next practice, the next game and the next contract. They know their job security is dependent on being available and that availability, in their view, is compromised by head injuries. Thus they cheat the test to eventually cheat themselves.

Having been both an agent and team executive, I understand. Players, especially marginal players trying to make or stick on a roster, know their time is limited. This is the sad and stark truth of the NFL: "So many players, so few jobs."

Liability

Unfortunately, players may face unanticipated consequences of the new awareness on concussions.

The NFL and team lawyers, concerned about future liability, are discussing contract language releasing teams from future concussion-related liability. And even if these clauses are not inserted and/or are allowed in player contracts, teams can steer clear of future liability simply by avoiding players with that history. Just as knees and shoulders are factored into a medical grade in rating a player, head injuries will be increasingly factored into that grade going forward.

These are unforeseen downsides for players entering the NFL with no leverage and competing with hundreds of others for a finite number of jobs.

Here to stay

The concussion conundrum is complicated and intricate, but one thing is clear: It is not going away. On the field, it will generate discussion of treatment and return-to-play issues every week as it is now with Griffin and Best. Off the field, former players continue to sign up as plaintiffs, seeing no downside with attorneys' fees being contingent and not knowing what symptoms will develop later in life.

With a 10-year CBA in place with the players, an eight-year CBA in place with the referees, new television contract extensions at record levels and skyrocketing asset values of teams (the Browns' sale for $1 billion was approved this week), these are salad days for NFL ownership. The concussion conundrum threatens to be the major ripple to these calm waters. Stay tuned.