Ruby Rivera did what she had always been told.

The Illinois shortstop had a hunch to play closer to second base on a sunny Saturday in the fall of 2013. She knew the runner at first base was fast.

The batter swung and missed; the runner sprinted toward second. The runner’s left knee jammed into Rivera’s chest, causing her to flip — the way she thinks her brain did in that instant.

The moments after the incident were unfamiliar: walking was hard, her balance was off, she couldn’t see through one of her eyes.

It was just the adrenaline, she thought.

She fell victim to the thought process that is common among athletes who want to impress their teammates: Play through the pain.

Rivera didn’t know, however, that this decision as a freshman would irrevocably affect her health and understanding of concussions, a complex injury.

“I immediately knew something was wrong,” the now senior said of the 2013 incident. “I was just trying to earn my spot and show that I’m tough. So I couldn’t take myself out of the game because I felt like I would be weak.”

She passed out in between games. Her teammates told her she was pale as a ghost.

She couldn’t see; she wanted to throw up.

When she was in high school, she had been in a similar collision on the field. Then, her coach was more concerned that she had been called out than if she was hurt. With that incident, the repercussions then weren’t as pronounced.

“I wish I was more educated on (concussions) before coming in, realizing how sensitive and cautious we need to be about concussions,” Rivera said.

Many female athletes share Rivera’s cluelessness about concussions. Despite preliminary evidence that females may be more prone to concussions, football tends to steal the spotlight on all matters concussion-related.

That means young women and their families are often left undereducated on an issue that can affect them for the rest of their lives. Coaches and athletic administrators, some of whom are also undereducated, are trying to address concussion concerns. Is that enough? What should parents and players do?

Chapter I A parent’s fear

A parent’s fear

A couple miles north of the University of Illinois campus, Katie Stafford sits at the top bleacher with her husband and one of her daughters. Inside the Soccer Planet facility in Urbana they are sheltered from a cold December afternoon.

The warehouse is filled with girls yelling inside a rink-like soccer field and the rubbery aroma of FieldTurf.

Stafford sits and watches as her older daughter, Kaitlyn, 13, plays for the Illinois Football Club. The regular season is over, but the girls aren’t done playing; they’ve just moved indoors for a couple of weeks.

Stafford shares laughs and concerns with her family and other parents, but throughout every joke, complaint or cheer, the fear of concussions hides in the back of her head.

She doesn’t pace around the outskirts of the rink every time her daughter plays; she’s aware ankle and knee injuries are more common than concussions in soccer.

“I think if I worried about all the things that could happen to her on the field, I would make myself crazy,” she said.

But Stafford knows a bit about concussions and what they mean. She is the secretary of the club’s board and has had first-hand experience dealing with head injuries.

Kaitlyn suffered a mild concussion when an errant ball hit her in the nose during a game earlier this year.

Stafford and the coaches handled Kaitlyn’s injury within the club’s protocol — she was held out until she could pass all of the appropriate tests — however, Kaitlyn’s concussion didn’t fall into the category of head injuries U.S. Soccer and Illinois Youth Soccer are trying to eliminate.

In November 2015, U.S. Soccer announced a ban on players 10 and younger using their heads to hit the ball. Illinois Youth Soccer has adopted this rule.

“These guidelines are a major victory for the Safer Soccer campaign and a fantastic first step in making the world’s most popular sport safer to play for children,” U.S. Soccer wrote in a press release. Both U.S. Soccer and Illinois Youth Soccer failed to respond to multiple requests for an interview.

The rule change caused more frustration from parents than it did for players, according Kevin Love, executive director and director of coaching for Illinois Football Club. Stafford attributes the outcry to some parents’ disdain for others telling their children what to do.

But both the two argue that headers aren’t as common in the 10-and-younger game.

Coaches at that age level echo Stafford and Love’s opinions — heading shouldn’t play into that age group’s style of play. They agree the ball should stay on the ground and both boys and girls should focus on fundamentals rather than trying to head the ball.

But rule change shows that there is a shift in the way the world and governing bodies look at concussions. There is training and education for young players now, and they are told tell a coach or trainer if they’re injured.

“The no heading is a very significant step for U.S. Soccer to take,” Love said. “That in itself shows that they are serious about it.”

Chapter II The known and the unknown

The known and the unknown

Dr. Brian Hainline decided to take an unfamiliar path from some of his peers, who were focused on football-related head injuries. The NCAA’s chief medical officer had a different concern: concussions in women.

“(It’s) a societal issue,” Hainline wrote in an email. “Concussion coverage is dominated by men’s football for reasons that go beyond an interest in concussion.”

Hainline wrote a column published on NCAA.org in which he discussed his theory that female athletes take longer to recover from a concussion and that they concuss differently from a biomechanical viewpoint.

He draws upon the similarity between migraines and concussions because they share similar pathophysiological expressions. Women are more susceptible to migraines during childbearing years because of the fluctuation of estradiol hormone, which is why he believes women take a longer time to recover from concussions.

Dr. Shannon Bauman came to a similar conclusion at Concussion North in Barrie, Ontario. She found that women report more symptoms when initially assessed with a concussion and exhibit more characteristics of concussions overall than males.

According to her research, one-third of women continue to suffer symptoms after six months or longer.

The reason for the difference, though, remains a mystery for Bauman and her team.

“Further research needs to be done on gender differences in concussion,” Bauman wrote in an email. “We are just completing further research in this.”

Nearly a decade ago, a team led by Dr. R. Dawn Comstock, an epidemiologist and researcher at the Colorado School of Public Health, started to investigate the frequency of injuries that occurred in high school sports, how they happened and how long it took athletes to recover.

In the research, Comstock discovered that in sports where boys and girls use the same equipment and rules for the sport — soccer, basketball and baseball or softball — female athletes had a higher risk of concussion. Over the 10 years studied, women always had a higher rate of concussion, although the difference between the genders was not consistent.

These are preliminary results. All three researchers agreed they have just started learning more about concussions, especially in female athletes.

“The solutions must be multifaceted and evidence-based. Knowledge is important but is insufficient, as knowledge does not change culture,” Hainline said.

“We need evidence-based educational and research paradigms to change the culture of sport.”

Chapter III Mistakes from the past

Mistakes from the past

Alex Booker didn’t know any better.

To she and her teammates, missing the baseline concussion testing at the beginning of the season didn’t seem like a big deal.

“If you’re an 18-year-old, what’s it to you to take a concussion test?” said Booker, a former member of the Illini softball team. “You don’t think that way. It’s just another test you have to take and more time wasted.”

But if a concussion actually occurred, there would be no basis for comparison.

According to Booker, players didn’t have to sign an agreement to take the test. If a player missed an appointment, she’d try to reschedule, even though she usually never did.

“It’s hard to pass something that you don’t know what that original score was,” Booker said.

Booker played volleyball, basketball and softball in high school, but it wasn’t until she started watching college sports when she first heard the word concussion.

She didn’t know what they were, but now, she thinks she has suffered a few, including one playing a summer league basketball game when a player ran into her, causing Booker to hit her head on the floor.

But Booker faced the same battle Ruby Rivera fought years later.

“Was I going to say anything?” Booker said. “I didn’t know if that was OK to feel or if it was not OK to feel. I didn’t know. I never would have known any different.”

Since Booker graduated in 2014, the sports medicine team at the University has made preseason baseline testing mandatory for every team, even noncontact ones.

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This reflects a changing understanding of concussions within the sports community.

Randy Ballard, associate director of athletics, sports medicine, remembers 10 years ago when there was no set protocol for how to handle a concussion. Now, Ballard and his staff must submit its official protocol and send it to the NCAA annually.

“I definitely think (the culture has changed),” Ballard said. “I think people are more aware of the need to evaluate is this a concussion or not? Twenty to 30 years ago, it’s just a headache. Now, it’s let’s evaluate.”

Athletes and coaches go through concussion training at the beginning of each season and additional lessons throughout the year. It’s part of an evolving process when athletes are learning more about an injury that has for so long been a mystery.

“It just truly makes me happy that they’ve taken such a precaution on me as an athlete, that they care,” Booker said. “As an athlete, you want to be out there doing your thing, you want to prove everyone you’re strong, but you need to show that you’re smart, besides just strong.”

Chapter IV Solutions

Solutions

Jeff Skeen was pissed off when he entered the world of protective soccer headbands and founded Full 90.

After all that his daughter had gone through, he’d had enough.

They had thought that soccer was a safe sport, but that changed in 2001 when Lauren Skeen suffered a concussion after a head-to-head collision with an opposing player.

Six months later, she was involved in an identical play with a graver result: a grand mal seizure. Skeen watched as his daughter suffered a loss of consciousness and violent muscle contractions in the middle of the field.

That moment and the ensuing hospital trip led to the creation of Skeen’s first concussion-prevention headband — one with two pieces of padding on either side. To him it was simple; it’s better to create a cushion between a player’s head and the object with which the player makes contact.

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But not everyone thought like Skeen. His daughter wore the headband during warmups, but a referee told her to take it off or she couldn’t play. All she could do was look up at her father and throw the headband to the sideline.

Six minutes later, it happened again: head-to-head collision, her third in two years — the start of a grueling six-year recovery.

“Watching your daughter go from an A student to barely a D/F student because they can’t remember anything and seeing their dreams of playing soccer just vanish and all the anxiety and depression is just unbelievable,” Skeen recalls.

Following her final injury, Skeen founded Full 90, one of several headband companies trying to reduce the risk of concussions. Skeen believes no company can claim to fully prevent a concussion, but if headbands meet testing material standards, they can reduce the risk.

But as he’s seen before, not everyone shares his thinking.

In 2003, the U.S. Women’s National Team practiced against his daughter’s team in preparation for the World Cup. According to Skeen, a few of the U.S. players saw his daughter’s headband and were interested in wearing it.

But the governing body meant to protect players stepped in.

Skeen says U.S. Soccer told the alleged players they wouldn’t play for the team if they wore those headbands, a direct order from FIFA.

“They don’t want soccer moms to think this game is dangerous,” Skeen alleged.

Neither U.S. Soccer nor FIFA responded to interview requests for this story.

“They’re not saying it on their own, so parents have to figure it out based on common sense that could make sense to protect our kids’ heads,” said Jim Caldwell, founder of Unequal, another headband company.

And that assumes that league rules allow the headbands.

“I think the majority of people really do know, they know what a concussion is, but I don’t know if they know what that means long term for their kids and if that’s actually causing brain damage,” Katie Stafford said. “I feel like we talk about concussions in the short term. We don’t want them playing when they have a concussion, but I don’t people know why it is that concussions are so bad.”

Chapter V Hope

Hope

What’s next isn’t clear.

There’s still research to do, but the process has at least started.

Professional athletes are leading the movement. Although little is known about Chronic Traumatic Encephalopathy, or CTE, level, there is evidence that CTE can take place in male soccer players.

The degenerative disease of the brain found in athletes, most often football players, isn’t exclusive to any one sport, but researchers such as those at the Boston University’s CTE Center face a problem: They can’t establish conclusive evidence without examining brains.

“For a thing like women’s soccer, it just hasn’t really penetrated the public conscious yet,” Boston University CTE Center researcher Bobby Abdolmohammadi said. “We haven’t really gotten any brain donations from this demographic. It’s hopefully something we can look at in the future, but it’s definitely a longer term thing.”

This is where athletes like Brandi Chastain and Abby Wambach come in — both have pledged their brains for concussion research.

For now, it’s just learning more.

“There is hope,” Hainline said. “There has never been a greater spirit of collaboration among the governing bodies, medical organizations and higher education organizations than there is at present. This … will help assure that we continue to move in a positive direction.”

Sometimes hope is all you can do.

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