For many, it's somewhat of a silent epidemic that is turning into a loud problem.
High school athletes are suffering brain injuries at alarming rates, and the research is staggering.
According to the Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control, the number of brain injuries in teenagers is between 1.6 to 3.8 million per year.
That's far too many, say local coaches and athletes.
"It's not worth the risk anymore, with all the stuff that's coming out with the long-term effects with having multiple concussions," St. Francis High football Coach Jim Bonds said. "When you have one, you're a lot more susceptible to having another."
Research behind the concussions has provided other distressing information.
A 2005 study by the Michigan State University Kalamazoo Center for Medical Studies showed that the highest number of sport-related concussions have been reported in football.
Most recently, a 2012 study in Michigan discovered that student-athletes are at risk of neurocognitive deficits that may last for more than a year, and concluded that eliminating tackle football for players under 16 is recommended to reducing concussions.
A majority of the studies have focused on football, including one by the University of Michigan that investigated the cumulative number of head impacts and their associated acceleration burden in 95 high school football players across four seasons of play. Using the Head Impact Telemetry System (HITS) — software installed in helmets that recorded the frequency and severity of impact to a player received during games and practices — the investigation revealed athletes received 101,994 impacts across 190 practice sessions and 50 games.
The number of impacts per 14-week season varied by playing position and starting status, with the average player sustaining 652 impacts. Linemen had the highest number of impacts per season (868), followed by tight ends, running backs, and linebackers (619); then quarterbacks (467) receivers, cornerbacks, and safeties (372).
Local administrators, coaches, trainers, parents, and doctors are trying to tackle the delicate and difficult subject.
Even California legislators have become involved. Legislation that would require high school coaches to receive training in concussions was sent Monday to Gov. Jerry Brown. Assembly Bill 1451 cleared its final hurdle Monday in the Assembly, which voted 65-0 to move the bill to Brown.
The measure would require high school coaches to receive training every two years on recognizing the signs of concussions.
"People are a lot more cautious," said first-year Glendale Coach John Tuttle, a former standout at San Marino High who admitted that concussions were not discussed during his playing days in the 1990s. "It's not worth the risk."
Football is often violent and concussions have been a part of the fabric of the sport for decades. Only recently have concussions become a national issue, brought on by the news of suicides of prominent NFL players who sustained years of brain trauma.
"It was never anything we discussed back when I played," said Hoover Coach Andrew Policky, who graduated from Arcadia High in 1998. "I could remember a time when I got my bell rung. I didn't even think to go over to the trainer. Nowadays, there is protocol in place."
As a player, Policky shrugged off headaches and injuries to become a stalwart wide receiver. As a coach who will enter his second year at the helm of Hoover's program, he would still like his players to play through minor injuries. But Policky won't take a chance on letting a player fight through concussion issues, even when a player tries to prove his toughness to a coach and his teammates.
Long-term brain trauma is not worth the risk, he said.
"Nobody knows their body more so than themselves," Policky said. "At the same time, it's our responsibility to look out for the responsibility and safety, especially in a sport like football when everybody wants to measure your toughness. You have to fight against that as a coach and do the right thing."
Bonds, Tuttle and Flintridge Prep Coach Antonio Harrison all concurred.
Players during Bonds' playing era — he graduated from Hart High in 1987 — suffered concussions, too, but the treatment for a head injury was different.
"You go get a drink of water and get back in there," he said.
Today, the decision of whether a player gets back in the game or sits for a day or weeks is not necessarily in coaches' hands.
"It's in the training staff's hands," Bonds said. "We have a doctor on the sidelines of every game. They're giving them every test they know to see if they have [a concussion] or not. That's one thing we're pretty lucky we have."
Harrison understands the tough nature of football. He forfeited two Flintridge Prep games in 2011 due to injuries that resulted in him suiting 16 or "hopefully" 17 players. He didn't want to take the risk of having further injury.
"It ate me up every night," said Harrison, who was a three-year starter at Flintridge Prep before starting for four years at Grinnell College in Iowa as a safety. "I think I'm the first coach in Rebel history to forfeit a game. That hurts."
To Harrison, there's a way to reduce the number of concussions: Improve tackling. His theory was one of his focuses in his master's thesis on behavior analysis.
"From 2001 to 2005, in the United States, there were more than one million visits to the emergency room for football-related injuries," Harrison wrote in his thesis. "Many of these injuries can be a result of poor and unsafe tackling."
Harrison fears the game might change too much to where it might become unrecognizable to what it is today.
"My biggest fear, with mainstream media and public opinion, the whole suicide thing, I'm scared that in 15-20 years football will no longer be football and it's going to turn into soccer or rugby," he said. "To me, football is a special sport. Once you hang up the shoulder pads and helmet, it's over. I don't want the sport to go anywhere. I hope people understand what they're getting into."
The Glendale Unified School District understood the dangers in football and provided a major equipment upgrade for CV, Glendale, and Hoover in 2011. GUSD Superintendent Dr. Richard Sheehan and the district picked up the tab to replace all of the teams helmets with the Ridell Speed model, which was given a five-star rating in a study by researchers at Virginia Tech.
The helmets are not a magic shield, though, coaches noted.
"Sometimes the helmets might be too good," Bonds said. "People have this false sense of security."
Along with the new helmets, trainers from the area have been provided specialized training to ensure the safety of players.
Kerrie Smith, an athletic trainer at Glendale High who is also employed in the outpatient physical therapy department at Glendale Adventist Medical Center, was one of the trainers who attended the National Summit on Sports and Other Athletic Injuries Institute on June 22 in L.A., where they learned more about gender and other variables related to concussions, and the evolving state of science in return-to-play decisions.
Smith said there are a variety of factors that contribute to her decision of allowing an athlete to return to play after sustaining a concussion. A player needs rest, needs to have light aerobic exercise, like a stationary cycle, and should be in non-contact training drills and have a full medical clearance before stepping foot on a field.
"I want absolute rest," she said. "No phones, no texting, no video games, no TV.
"I want them to relax and let their adolescent brains heal."
Study on the age of players and the construction of the brain has played a significant role.
Research shows that high school athletes — whose frontal lobes of the brain continue to develop until the age of 25 — not only take longer to recover from a concussion when compared to collegiate and professional athletes, but they have greater severity of symptoms.
"The kids are more prone [to concussions]," said Dr. Lance Lee, a neurologist at Glendale Adventist. "They probably don't know what they're going through.
"The recovery after concussions depends on the level of the injury. It depends on how long they were out, and whether or not they lost consciousness."
Glenoaks Imaging Professionals Inc. has attempted to help local coaches deal with concussion issues among their players.
Andre Shakhbandaryan, a Glendale High graduate who is a co-owner of Glenoaks Imaging, will provide free MRIs to local football players if they should suffer a concussion. Shakhbandaryan, who was a MRI technologist with the Clippers in the 1990s, reached out to local football coaches after learning about the suicide of Junior Seau, a former USC and NFL star who died May 2. Shakhbandaryan worked with Seau, performing MRI scans on him while he was with the San Diego Chargers.
"I had the pleasure of meeting him and scanning him. That part hit home with me," Shakhbandaryan said. "We're trying to make it a way where locals have access."
Now they have access and more and more, coaches and players are developing awareness.