Steve Young took the first hit on his chest, just under his chin and at the top of his red No. 8. Then, in whiplash action, the back of his helmet caromed off a teammate's knee and the grass surface of Sun Devil Stadium in Tempe, Ariz.
Just like that, the intense quarterback for the San Francisco 49ers was revisiting no-man's land last Monday night. Out like a light for several long seconds, Young's past and future conspired to paint one frightening picture of a proud athlete on the edge.
When consciousness returned, Young found himself back in the center of a controversy over how to deal with an injury that endangers wide receivers and defensive backs as well as quarterbacks. His fourth concussion in three years focused attention on how sports leagues handle concussions and whether athletes should have the final say in deciding when -- or if -- they can resume playing.
For those seeking signs of progress in the NFL, there is this. In 1997, when Young was kneed in the head in the first quarter at Tampa Bay and suffered his third concussion in 10 months, he was allowed to re-enter the game in the fourth quarter.
On Monday, when he was knocked out of a game against the Arizona Cardinals on a clean but fierce hit by Aeneas Williams, he was not permitted to return. Although he tried.
"He asked me [to go back in]," 49ers coach Steve Mariucci said the next day. "I simply said, 'Steve, you're not going in.' He says, 'I can play.' The doctor was there and I said, 'Doc, what do you think?' He said, 'Hold him out.'
"I told Steve to stay out. He's a lawyer, he's going to debate, he's going to negotiate, he's going to try and convince you that his point of view sounds good."
In the rush to return to action, oft-concussed quarterbacks like Young and Troy Aikman of the Dallas Cowboys are caught in the middle of a riddle. Do you play on or do you play it safe?
And who ultimately makes the decision about when and whether an athlete can return to the field for practice or a game when he has had a head injury?
In Young's case, as with most players, it is a combination of opinions.
Doctor and patient
"I think the doctor has the predominant say because they have the most experience and as much diagnostics as possible," said Young, who has been ruled out of today's game against the Tennessee Titans and perhaps next week's game at St. Louis.
"And I have a lot of say, too. If I'm honest with myself with what happened and what has happened [in the past], then clearly you talk to your family, your girlfriend, and all of the people that are really important to you."
It is equally clear that evolving research needs to arrive at an agreed-upon protocol that makes it more difficult for the star player or the obsessive coach to second-guess or overrule a medical decision.
Scientific research has established that once a player has a concussion, he is more at risk in the next game, week and season. That makes an impartial decision more vital. One of the problems with the system now is that the injured player does have a voice. And denial does play a role.
"Certainly, athletes in general -- especially elite athletes -- have a much stronger sense of invincibility than the rest of us," said Dr. Andrew Tucker, a team physician with the Ravens and director of primary care sports medicine at University Sports Medicine at Kernan. "Whether it be a head injury or a muscular-skeletal injury, their acceptance of that comes a little slower.
"On the other side of the coin, you're talking about an injury that does affect judgment. It's like trying to figure out a person's judgment when they're under the influence of alcohol."
Many careers ended
Concussions have driven any number of players from the game, among them quarterbacks Roger Staubach and Stan Humphries and wide receivers Al Toon and Don Beebe. In a book written by Ronnie Lott, the former 49ers safety estimated he had no less than 12 concussions in his career -- and lied about his recovery to get back on the field.
Aikman suffered the seventh concussion of his career in a 1997 game against the Philadelphia Eagles, and played the following week against the 49ers.
Humphries was forced to retire from the San Diego Chargers after the 1997 season, when he endured three concussions in two months, and two in successive weeks. The one that ended his career came after a hit under his chin by Cincinnati's Reinard Wilson.
"It was one of the worst," said Humphries, who estimated he had between 10 and 12. "I lost a little feeling in my right leg for an hour or two. It was real scary. That was the last time I was on the field."
The list of concussion patients this season already includes some prominent names:
Miami Dolphins linebacker Zach Thomas suffered one in a preseason scrimmage Aug. 1, and when he tried to come back a few days later, saw flashes of light when he made contact. He sat out two weeks of training camp but missed only one preseason game.
49ers running back Lawrence Phillips had a "mild" concussion in Week 1 returning a kickoff, but missed no time.
In Week 2, Green Bay Packers tight end Mark Chmura was hit in the back of the head by Detroit linebacker Chris Claiborne when he was on the ground, and came away with a concussion and a stinger, or numbness in his limbs. Chmura won't play again this season -- if at all -- because of a disc injury.
In Week 3, Jacksonville wide receiver Reggie Barlow, Carolina center Frank Garcia, Buffalo quarterback Rob Johnson and Young all had concussions.
The league is concerned about the trend. In 1997 -- the season Aikman, Young and Humphries all were hurt -- the NFL poured $1.1 million into university medical research grants to study the components and long-term effects of mild traumatic brain injuries. The study is not yet complete.
In December 1997, a group of 21 representatives of medical societies whose members treat athletes and major national professional and collegiate sports leagues -- including Dr. Elliot Pellman, team physician for the New York Jets -- met to formulate guidelines on concussions. The recommendations were published in the current issue of the American Journal of Sports Medicine.
What happens to the brain
In the Sept. 8 issue of the Journal of the American Medical Association, research was published that indicates a concussion may impair an athlete's intellectual function. One member of the team that prepared the report offered an explanation of why violent collisions have become such a troubling part of professional football.
Dr. Michael Collins, of the department of behavioral health at Henry Ford Health System in Detroit, pointed to the laws of physics that apply when stronger, quicker 300-pound linemen and 250-pound linebackers bring down smaller quarterbacks and wide receivers.
"That's why concussions are becoming a greater problem," Collins said. "Mass is important when you've got more and more 300-pound linemen who can run a lot faster than they have in the past."
The resulting collisions, in effect, jostle the brain.
"If you think of the brain as an egg yolk inside an eggshell, if I twist it quickly, you won't see the egg break," Collins said. "But the yolk sloshes around inside. When a football player takes a hit, the head twists, so it's like the egg.
"For example, the Steve Young hit this week -- he got hit in the chest -- it's the whiplash that happened. He didn't hit his head on something hard, but something that moved him quickly from one spot to another caused the brain to slosh around."
Collins allowed that there is no way at this point to measure the severity of a concussion. He defined a bad one, intuitively, as when an athlete is confused for an extended time (for 15 to 20 minutes) and can't formulate memories, or loses memory of what happened before the hit. Another definition, he said, is an athlete who loses consciousness for more than 5 to 10 seconds.
"I'm a former athlete [college baseball] and when you have a mild strain or groin pull or tear, you'll just decide to play at 75 percent," Collins said. "You just tape it up, go back in there. Well, you can't tape the brain. You need to treat a mild head injury different from a mild knee sprain."
Future risk in dispute
There remains a dispute about whether a player returns to a baseline level of risk once his brain has healed, which most research says requires a week or longer.
But it is commonly agreed on that there is a real vulnerability when a player returns too soon after the injury. If a player is hit in that vulnerable state, the consequences would be more severe.
That player risks "second impact syndrome."
"We don't see it a lot," said Dr. Kevin Guskiewicz, who conducts concussion studies as director of the sports medicine research lab at the National Center for Catastrophic Sport Injury Research at the University of North Carolina in Chapel Hill.
"The axons [part of the neuron] in the brain are not totally healed and a second blow in that week, the brain swells and herniates and can end up in fatality or with permanent damage. It's rare, but that is the risk they are faced with if they return to play prematurely."
Guskiewicz's research focuses on the number of repetitive blows players take. His group recently studied 18,000 football players at the college and high school level who had about 1,000 head injuries among them.
"All fingers are pointed now at the number of blows and the number of head contacts," he said. "The research we just finished has shown that once you've had one concussion, you are three times more likely to sustain a second in the same season after that initial injury.
"That right there tells you that Steve Young had a concussion this past Monday night and he's only at Week 3 of the season, and he's already at a threefold risk of sustaining another one."
NFL teams have at least one team physician on the sideline at all games to make assessments and recommendations on player injuries. The league has also begun to use neuropsychological testing in an attempt to identify problems. The neuropsych tests are a battery of tests that deal with the retention of information and the ability to concentrate.
The Ravens have a neurologist (Dr. Andrew N. Pollak) at all their games, said Ozzie Newsome, the Ravens' vice president of player personnel. He said the team entrusts all injury decisions to its medical staff.
"Myself, Brian [Billick], Jimmy Johnson, Bill Parcells, we don't have medical degrees," Newsome said. "For us to try to play doctor can be damaging to us and to the player. It's all in our medical people's hands. Our medical people are like an offensive or defensive coordinator."
Gene Upshaw, executive director of the NFL Players Association, said more research is needed to deal with the issues.
"I don't think you can legislate this," he said. "We in the NFL are very aware of this problem. Look at the position -- normally, [the injured player] is the highest-paid player. We think we take every precaution."
Getting the latest news
What the NFL is attempting to do is bring the most up-to-date research to the people who must make the most important decisions -- on the sideline and after a game. Some players, like Miami defensive end Trace Armstrong, take the initiative, though.
Armstrong, the president of the NFLPA, investigated options for a new, improved helmet in the off-season. He got one from Bike Athletic manufacturers last Friday and will wear it in tomorrow night's game against Buffalo.
The new helmet, he said, is 40 percent lighter than the Rydell model that all other NFL players use, and has a poly-propylene liner, which is used in bike and motorcycle helmets.
"I'm an amateur race car driver," said Armstrong, an 11-year veteran who turns 34 on Tuesday. "And it struck me as being odd that the helmet they use in auto racing is more advanced than we use in football. Our helmet hasn't changed since I was 7 or 8. I know there's a lot of technology out there.
"There was and is clearly room for improvement. I'm not saying it [Rydell] is a bad helmet. But there are other options out there."
Among the other safety issues the union needs to explore are the decision-making process and the playing surface, Armstrong said. He hinted that the NFLPA might want to consider conducting its own study, as well.
"We've got to start finding answers on our own," he said.
Sun staff writer Gary Dorsey contributed to this article.
The American Orthopaedic Society for Sports Medicine issued recommendations for dealing with concussions in an article published in the current issue of the American Journal of Sports Medicine. Here are excerpts:
When a concussion occurs, the athlete should be observed and evaluated for a minimum of 15 minutes. Medical personnel may allow the athlete to return to play if there was no loss of consciousness and all signs and symptoms are normal. If the athlete's symptoms do not abate during the 15 to 20 minutes of observation, the athlete should be disqualified from that day's competition.
A small number of athletes may require subsequent evaluation by a neurosurgeon or a neurologist because of persistent symptoms. Caution should always be exercised by the medical staff responsible for making return-to-play decisions because the athlete's motivation as well as peer or coaching pressure may be significant factors.
If a neurological evaluation at any time reveals any deterioration in mental status or a loss of consciousness after a concussion, immediate transport to an emergency facility is indicated.