Carly Tinstman, a junior soccer player at Sanderson, sat on the doctor’s table with her head bowed. Tinstman’s hands were locked together. She had no control of the decision that was coming.
Tinstman’s mother, Cindy, sat next to her daughter on the table in the tiny room at Carolina Family Practice & Sports Medicine on May 7.
Jude Carr, a physician assistant, soon walked in to render the verdict on Carly Tinstman’s athletic future.
Tinstman, a goalkeeper who has suffered three concussions, didn’t look at Carr when he began speaking.
“I think you look good,” Carr said. “You’re ready to go back out. How does that sound?”
Those three short sentences were what Tinstman had waited more than four months to hear. She smiled and nodded in her white Sanderson soccer T-shirt.
But there was more for her to hear. If Tinstman, 17, has another concussion, Carr will advise her to stop playing soccer.
“You can get hit in the head and maybe you feel a little dizzy, but you don’t think about it,” Tinstman said of her concussions. “You don’t want to think about it.”
According to this month’s issue of The American Journal of Sports Medicine, girls who play soccer are suffering more symptoms from concussions and taking longer to recover than boys. Among girls, soccer has the most diagnosed concussions of any sport, and girls are more likely than boys to have a concussion in the sports that are offered to both groups. During the 2005-06 school year, the Journal of Athletic Training found concussions represented a greater proportion of total injuries in girls soccer (15 percent) than in any other sport.
Tinstman understands all of this. She knows playing soccer is the biggest gamble of her young life.
“I love soccer,” said Tinstman, whose high school and club coaches say she is one of the best goalkeepers in the state. “There’s nothing like it when you’re out there. I don’t like watching soccer.”
Once Carr cleared Tinstman to play, her mother asked all the questions.
Tinstman kept her head down. She was excited. But she couldn’t show it in that moment – she was thinking about all the risks.
Three days later, Tinstman played in the Spartans’ first round playoff match against East Chapel Hill.
Studying the injury
Dr. Micky Collins is a concussion expert at the University of Pittsburgh Medical Center. As the director of UPMC’s Sports Medicine Concussion Program, Dr. Collins has studied the injury, a change in the brain’s chemistry that can result from jarring blows to the head, since 1997.
In the book “The Concussion Crisis,” written by Linda Carroll and David Rosner, the injury is defined as any change in mental status such as confusion, disorientation, headache or dizziness following a hit or jolt.
Dr. Collins helped develop the Immediate Post-Concussion Assessment and Cognitive Testing, a computerized evaluation used for athletes who suffer a concussion. Tinstman has taken the ImPACT test at least eight times.
The National Federation of State High School Associations says more than 7.6 million students participate in sports. According to federal research, more than 150,000 teenage athletes were taken to the emergency room for concussions from 2001 to 2005.
Every year, Dr. Collins said he sees about 15,000 athletes from all levels of sports with concussions. He helped NHL star Sidney Crosby recover from his concussion symptoms the past two years. This month, Dr. Collins advised two amateur athletes to retire on the same day. A Division I football player was one of them.
“I’m retiring a lot of kids,” Dr. Collins said. “I’ll do everything possible not to. I want kids to play sports. My job is to get these patients back on the field safely.”
Dr. Collins says Tinstman’s story is a familiar one.
“There’s an increased vulnerability in girls,” Dr. Collins said. “We don’t know exactly why.”
Based on his research, he does have theories. Dr. Collins said girls are four to six times more likely to have migraines than boys. He believes migraines are the main reason girls suffer more concussions.
Another reason is the neck.
Dr. Collins said the neck stabilizes the head. If the neck is not strong, the head, and the brain inside it, will move with more violent force. Dr. Collins said girls tend to have less neck strength.
Tinstman used the exact attribute – neck strength – in her first match as a goalkeeper.
When she was 6 years old, Tinstman’s coach told her to be the goalkeeper.
“When you’re young,” Cindy Tinstman said, “no one wants to be the goalie.”
Tinstman and her husband, David, watched their daughter make one of her first saves by having the ball bounce off her neck instead of landing in the net.
“The crowd went silent,” David Tinstman said. “We’re thinking, ‘Is she OK?’ When she popped back up, we just said ‘Wow.’”
From that moment, Carly Tinstman, who has been offered a full scholarship at Western Carolina University, has been a goalkeeper.
Managing the risk
Experts say most girls soccer players have concussions by heading the ball with improper technique. Tinstman’s three concussions were different.
In 2007, with her Capital Area Soccer League club team, Tinstman was hit by an opposing player when she dove for the ball. A pediatrician conducted a CT scan and cleared Tinstman after two weeks of rest. Researchers now realize CT scans cannot show a concussion.
Tinstman’s second concussion came after Sanderson’s 2-1 win over Broughton last April. In that match, she dove to her right to secure the ball, and the victory, with less than a minute left. But Tinstman also remembers how she was kneed in the head by a Broughton player earlier in the match. The next day she was sent to WakeMed Emergency Department.
The third concussion occurred in late December with her CASL team. Tinstman had head-to-head contact with another player on a corner kick.
“I remember looking at my teammates and just shaking my head because I knew,” Tinstman said. “ Not again.”
Charlie Slagle, the CEO of CASL, said the league has implemented a new rule this year that players must be removed from the match if the coach or athletic trainer believes the player might have a concussion. In order for the player to return to the field, he or she must perform well on the ImPACT test.
The N.C. High School Athletic Association as similar rules. For a player to return, a physician or doctor must give the coach written documentation that says the player is medically clear.
Doctors say athletes are tempted to lie about how they feel in order to return to the field. Carr, who treated Tinstman, said she never lied to him.
“It’s tough as a youth to make such a decision,” Carr said. “There’s a lot of outside pressure.”
With each case, Tinstman was instructed to rest and sleep in her bedroom until her symptoms – the dizziness, the slurred speech and the blurred vision – subsided.
Dr. Collins said treatment for concussion should be, and has become, more than just rest in the dark.
“Sitting in a dark room and not doing anything is not going to get someone better,” he said. “We need to become more proactive in our approaches.”
Since her last concussion, Tinstman has taken Docosahexaenoic acid, Dopamine and ADHD medication. Still, Dr. Collins said there is no treatment option that can prevent Tinstman, and other girls, from having another concussion.
“This injury takes a lot longer to recover (from) than people realize,” he said. “The brain is intricately complex. It has to be individually managed, individually assessed and individually rehabbed.”
Making it through rehab
Todd Worley has coached at Sanderson for 17 years. With each season, he is learning more about concussions.
Worley thinks five of his players suffered a concussion in his first 12 years. Since then, Worley expects about four Spartans to have a concussion each season. Last year, Worley watched five Spartans miss time with the injury. He believes the number of concussions on his team has risen because players are more physical and are being diagnosed better.
Tinstman was the only player with a concussion this season – and she suffered it before the season started.
“Carly is an excellent goalkeeper,” Worley said. “When you have a player of Carly’s magnitude, it’s difficult to watch her go through the pain.”
Worley believes the hardest part for Tinstman was being away from her teammates.
“You don’t want to treat her like she’s different,” Worley said. “But in reality, when she’s not at school and practice, she is disconnected from the group.”
Tinstman missed the majority of her schoolwork during her four-month rehab. Even now, she attends just three classes each day. Tinstman said life became unbearable at times. Not only was soccer gone, but her whole lifestyle changed.
“I was depressed through the whole thing,” she said. “You find out who is there for you and who is not.”
Kaylyn Braga became Tinstman’s best friend. Braga, a senior goalkeeper, talks to Tinstman every day. Braga was one of the players to suffer a concussion last season.
Braga expected to be the Spartans’ backup goalkeeper for this season, the player who would help Tinstman throughout the year. Instead, the two were forced to switch roles.
“I’ve never experienced anything like it,” Braga said of the situation. “It was difficult. I love playing with Carly.”
As the regular season ended, Worley didn’t expect Tinstman’s recovery to take so long.
“Carly is one of the best goalkeepers in the state,” Worley said. “I’ve probably not done a good job helping Carly.”
Worley said he lost sleep when he found out Tinstman was cleared to play in Sanderson’s playoff match against East Chapel Hill.
“I’m scared to death to play her,” he said days before the match. “I don’t want her to get hurt again.”
Returning to the field
In her bright yellow No. 12 jersey, Tinstman was happy and nervous on the bus ride to East Chapel Hill on May 10. Was she ready? Could she help Sanderson win? Would she suffer another hit to the head?
The answer to the last question came in pregame warm-ups. Tinstman, again diving for the ball, bumped her head against a teammate’s thigh.
“I didn’t think twice about going for the ball,” she said.
Just before the match, Braga wanted Tinstman to look at her mother. Debbie Braga hung a red sign behind the Spartans’ bench that read, “WELCOME BACK CARLY!” in black letters.
“It was heartwarming,” Tinstman said. “It was motivation to do well.”
Kaylyn Braga played the first half while Tinstman waited for her turn on the end of the bench. In the stands, way before her daughter saw the field, Cindy Tinstman was tense.
“This is going to be the longest 80 minutes of my life,” she said.
What she didn’t know was that the match wouldn’t be decided after 110 minutes, which included two overtime periods.
Sanderson led 2-1 when Carly Tinstman took the field after halftime. The Spartans extended their lead to 3-1. But East Chapel Hill played better as the match went on. Tinstman, playing through nerves, stayed aggressive. She dove and jumped to record eight saves.
Tinstman deflected a shot with less than two minutes in regulation. But the Spartans, up 3-2 at the time, couldn’t clear the ball out of the penalty box. Just when it appeared Tinstman had given Sanderson an upset victory, East Chapel Hill tied the match on a rebound shot.
Tinstman split the 30 minutes of extra time with Braga. She played her best in overtime. In the second sudden-death period, Tinstman extended her right hand as far as she could to deflect an East Chapel Hill shot.
“I just followed my instincts,” she said.
With penalty kicks to decide the match, Worley had to make a decision: Braga or Tinstman. Worley chose to have Braga, the senior, try to win the match. Tinstman stood in silence next to her teammates as the Wildcats defeated the Spartans 4-3 in penalty kicks.
“It was disappointing they weren’t going to move on, but there was some relief, too,” said David Tinstman, who attended many of Sanderson’s matches this season. “I was really amazed at how Carly came out.”
Carly Tinstman was the last Spartan to leave the field that night. She hopes that wasn’t her last match.
“I think it was (worth it),” Tinstman said of playing again. “It meant a lot to me and my teammates to go back out there.”
Because of CASL rules, Tinstman will be too old to play in the league this year. The long wait for her next high school match will continue to let her brain heal.
Tinstman plans to study sports psychology in college. She knows another concussion could end her soccer career.
For now, she has no plans to abandon the game she loves.