July 20, 2025
On a typical day in training, Riverhounds SC midfielder Robbie Mertz was standing away from the play when an errant ball came out of nowhere and hit him in the head.
He didn’t even realize he was injured until a day later. Or, to this day, what specific injury he had incurred.
“I felt a little bit lethargic and in a fog the next day, so they put me in the protocol,” Mertz said. “Whether I actually had a concussion or not, I’m uncertain because it was a five-day protocol.”
Mertz stayed away from on-field team activities and was a rare scratch in the Riverhounds’ 2-1 road loss to Loudoun United FC on April 19. But his absence in such a critical match against a conference foe is just a small example of how drastically perceptions, approaches and caution when dealing with head trauma and concussions have shifted since chronic traumatic encephalopathy (CTE) entered the mainstream sports vernacular 20 years ago.
“We’re still learning about how people respond to them and how it can affect the brain,” Riverhounds trainer Sam Cervantes said. “That’s still an ongoing research topic.”
CTE
And it’s hardly just professional athletes who are affected.
Diagnosis and treatment of concussions has expanded the science and research into neuropsychology. There are also guidelines in place for how to better protect the student-athlete and make a determination as to the severity of a head injury.
It is at this point an ongoing process.
Pennsylvania was among the first in the country to enact legislation regarding concussion safety. The Youth Sports Concussion Safety Act, also known as the Safety in Youth Sports Act, was signed into law on Nov. 10, 2011, in an effort to protect student athletes from the dangers of concussions.
It required education, training coaches on what to look for, mandated removal from play, set up protocols for a return to play, and required a “return to learn” to help students reintegrate into academics following a concussion diagnosis.
In 2014, the National Federation of State High School Associations held a concussion summit in an effort to reduce the risk of head trauma. The organization teamed with the Center for Disease Control to produce a 20-minute online course which addressed concussion management — mainly in football — and added bylaws adding penalties for helmet-to-helmet contact and other blows to the head.
Since that time, the NFHS has continued to offer the online course and, in October 2023, published a memorandum, “Suggested Guidelines for Management of Concussions in Sports” as well as a 2024 “Emergency Action Plan” addendum that covers a wide swath of problems that could crop up at sporting events, including head and neck traumas.
There are also several groups that have gotten on board to offer education and tips on prevention. Among the more prominent groups are the CDC with its HEADS UP program, the Youth Sports Safety Alliance based in Texas, and The Concussion Legacy Foundation out of Boston, which is one of the leading educators for CTE prevention.
Following with the NFHS directive, the Pennsylvania Interscholastic Athletic Association (PIAA) in 2014 defined concussion recognition and management as part and parcel of its eligibility rules. By state directive, if a player is removed from a game by an official after exhibiting symptoms related to a concussion — including but not limited to loss of consciousness, headache, dizziness, confusion or balance problems — a player cannot return to games, practices or scrimmages until cleared by a licensed medical or osteopathic physician familiar with concussion management.
Locally, the Western Pennsylvania Interscholastic Athletic League (WPIAL) has adopted these protocols, which have filtered down to the 12 districts that comprise the state.
“I think more has to do with what schools are doing. We know the PIAA is requiring coaching to take its courses and that type of thing and we monitor that as best we can,” WPIAL executive director Scott Seltzer said. “But it’s up to the schools and the precautions that they make because we don’t want to mandate unfunded costs on a school or those types of things. Schools take that very seriously and everyone is better educated in what to look for, what the signs are and preventing them by using proper techniques and things like that.”
No shying away
Though there has been a perceived cascade effect that has reached through the NCAA, high schools and even into youth leagues that student-athletes are opting against football and other contact sports because of concussions, the numbers don’t bear it out. Some parents, including former NFL players, are loath to have their children take up the game, but many more are at the forefront, encouraging their children to play despite the risks and with the knowledge that has been gleaned through intensive study and research.
In the 2013-14 school year, there were 7.8 million student-athletes at the high school level, with boys at 4.53 million and girls at 3.27 million, with football leading male participation at 1.09 million. By 2023-24, there was a slight drop in football to 1.03 million, while overall participation increased to a record 7.98 million.
While some opted to switch gears and walk away, that is not the prevailing sentiment.
“I think you accept the risks and know it’s a physical sport and there’s a lot of ways [a concussion] could happen in the game of soccer,” Mertz said. “It is a little scary when you get slowed down like that and you wouldn’t want to live like that forever, that’s for sure. That’s why they have the protocols in place that they do.”
Kim Kelley, a physical therapist specializing in concussions at Allegheny Health Network, knows about concussions from every angle. In her youth as a soccer player at Oakland Catholic and Chatham University, she suffered three concussions herself. She is now a therapist who helps in recovery and has children of her own who picked up where she left off and played soccer themselves.
“My daughter plays soccer and a lot of other sports, and I’m not going to shy away from having my kids play sports,” Kelley said. “It’s more that we are doing good testing and we’re making sure the kids and parents and coaches are all aware that, if kids get hit, they need to be pulled until cleared. So I think that has been great as far as awareness of what we’re talking about, about concussion, brain injury, but at this point there is still so much to be learned.”
First line of defense
This is no longer the era of waving smelling salts under a player’s nose and shoving them back into a game where the possibility of a secondary brain trauma is a serious concern.
In fact, everything has changed since CTE first became a household acronym.
“It’s been an up-and-down road in the last 30-35 years of high school football where I’ve seen some major ones and some minor ones and things that a lot of players took back in the day would now be considered concussions,” former Franklin Regional coach Greg Botta said. “We were told you’ll be OK, you got your bell rung, you’re just dizzy and you’ll be fine.”
Botta knows firsthand the short-term damage concussions can do. As a player, he suffered six major head traumas, including ones where he couldn’t recognize his parents and didn’t remember which team he played for.
“I probably had one playing for a sandlot team called the Morningside Bulldogs, and then I went to Central Catholic and I transferred to Penn Hills after we moved there and I had a major one there when I didn’t know I played for Penn Hills,” Botta said. “All I could think was that I go to Central Catholic, and why do I have a Penn Hills jersey on? And I don’t remember anything of that day. I had two more after that at Penn Hills, and then I went to Indiana University of Pa. and suffered two more, and I started coaching the freshman team there when I was 20.”
He also saw more than his fair share of player head trauma. During the 2017 season, he had eight of his players suffer concussions of varying degrees.
As the onus has shifted, athletic trainers have become the nexus for immediate diagnosis.
“I was out of state and came back in like 2005 and, at that time, I don’t even think we were doing baselines yet,” said Cara DiSalvo, Serra Catholic’s athletic director and longtime trainer. “Then, when we did do them, we gave the kids a piece of paper and sent them home to do them.”
No longer.
Now, athletic trainers at all levels do on-the-spot evaluations with players who are thought to have had major head or neck trauma.
“When it comes to on the field management, it’s really the [United Soccer League] has really stepped up their game and making sure that we’re being very comprehensive in our evaluations,” said Cervantes, the Riverhounds trainer. “In the event that someone sustains what appears to be a concussion or a blow to their head, the refs will immediately stop the game and wave us on. [Players] are actually not allowed to go back on until we give them the verbal ‘yes’ if they’re good to go or not.”
High schools are a bit different.
Unlike professional teams, most high schools don’t have a physician on site to make a concussion determination. Trainers must then decide whether the player is good to go, whether parents need to be brought out of the stands, and if they recommend an emergency room visit or a consult with their primary care physician.
Even so, it’s not always the highlight-reel collisions, some of which can bring about penalties in football, soccer or even hockey, that do the most damage.
“I’ve seen kids get blown up that are actually fine, so the first trigger is the mechanism and the second is how they react to it and to see if there’s anything obvious,” DeSalvo said. “You look and see whether they’re stumbling or if they’re really not with it. Just knowing them helps a lot to see if it’s a typical behavior, like if it’s a lineman, did they run the right play or if a receiver ran the right route.”
At the end of the day, though, science is still at its infancy when it comes to mapping the brain, concussive injuries, and the causes of CTE and other debilitating maladies.
“There’s so many crossover symptoms with CTE and there’s research out there suggestive of repeated head impact, but they don’t know how many is too many and they don’t know what the correlations are,” Kelley said. “There is still a lot of research that needs to be done about CTE.”