Alex Smith's Concussion: What Can Hold Back an Athlete's Return to the Field?

Dave Siebert, M.D.@DaveMSiebertFeatured ColumnistNovember 19, 2012

SAN FRANCISCO, CA - NOVEMBER 11:  Quarterback Alex Smith #11 of the San Francisco 49ers warms up before a game against the St. Louis Rams on November 11, 2012 at Candlestick Park in San Francisco, California.  Smith left the game with a concussion in the second quarter.  The teams tied 24-24 in overtime.  (Photo by Brian Bahr/Getty Images)
Brian Bahr/Getty Images

Concussions have been frustrating the NFL community recently.

Some of that frustration is based on how each concussion has its own unique symptoms, course and complications.

Now, no one understands that better than Alex Smith.

Smith was reportedly recovering very well and may have been on track to start tonight against the Chicago Bears after suffering a concussion in Week 10.

As ESPN's Chris Mortensen reports, that is no longer the case.


Something on his exam or testing showed that his brain is not yet healed.

Following a concussion, that "something" can be any number of things.

Though an athlete may feel back to normal, a skilled neurologist can determine that an athlete is still suffering from a concussion.

Concussions affect the cognitive and motor skills of the brain.  Among other problems, athletes suffering from concussions think slower and have difficulties with balance.

As much as Smith probably wanted to, he can't hide those deficits.

The ImPACT test is an exam designed to test visual memory, verbal memory and spatial reasoning among other tasks.

Athletes typically have a baseline test they take when healthy.  This sets the score to compare a post-concussion score.

Large differences between the two scores suggests an athlete is still symptomatic even if he or she does not feel so.

Additionally, eye tracking (following an examiner's finger with the eyes without moving the head) can suggest problems, as well.

If an athlete is still concussed, one eye may follow the finger more slowly than the other.  Such a finding suggests decreased blood flow to the back of the brain, another consequence of a concussion.

Finally, three different balance tests can also suggest an athlete has not yet recovered.

The tests include:

  • Balancing with two feet shoulder-width apart with hands on hips and eyes closed for 20 seconds
  • Balancing on the athlete's non-dominant foot with hands on hips and eyes closed for 20 seconds
  • Balancing with one foot in front of the other with hands on hips and eyes closed for 20 seconds

Significant difficulty with any of these suggests a concussion still persists.

All of that said, Smith failed a different test.

According to Chris Mortensen and Adam Schefter of ESPN, Smith failed the "exertion test" with contact practice:

As @mortreport reports, Alex Smith is out tonight. He could not get clearance on his contact test. Colin Kaepernick starts.

— Adam Schefter (@AdamSchefter) November 19, 2012

That means that when Smith returned to full contact practice, the last exertion test that he needed to pass before being cleared, his symptoms returned.

In other words, he still has his concussion.

That sets up a battle of backup quarterbacks tonight on Monday Night Football when the Bears visit the 49ers.

It's just another example of how the NFL landscape changes on a minute-to-minute basis.

Concussions have helped make sure of that.

The author of this article is a soon-to-be Family Medicine resident physician who plans to specialize in Primary Care (non-operative) Sports Medicine.  The information discussed is based on his own anatomical and clinical knowledge and experience in the evaluation and management of concussions under the direct supervision of Sports Medicine physicians and concussion specialists.  Additional input is welcomed and encouraged.


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