Dr. Richard Ellenbogen, co-chair of the NFL’s Head, Neck and Spine Committee, recently spoke with USA Today’s Jarrett Bell and talked about safety issues in the league.

Jarrett Bell: How could San Francisco QB Alex Smith and Chicago QB Jay Cutler have been allowed to return to play when it seemed so obvious to observers that they suffered possible head injuries?

Ellenbogen: You cannot tell on TV if a player is concussed.  It may be hard to believe, but true. … Sensors in helmets of college players may show large impacts but no symptoms of concussion and vice versa.   The physics of the hit do not always translate to a concussion.  The amount of impact does not always correlate to a concussion.  It is often related to angular acceleration, not linear acceleration of the hit.   You need to look at a player and have a baseline exam and compare to that.

I talked to the team docs.  Smith was concussed on the second hit, not the first.  Cutler was OK after the first hit but got new symptoms as the game progressed. Remember, the problem is that with all the adrenaline, the concussion was not immediately obvious to the players.  Both became symptomatic as they played further.  It certainly is not uncommon for concussions to evolve.  If you have seen one, you have seen one; they are all different.

Bell: Did the trainers in the press box weigh in on Smith and Cutler?

Ellenbogen: Trainers in the press box and team doctors called each other about the same time in both cases.  Doctors went over video in both cases.

Through the first six NFL games, more than 193 calls were made to the field from the press box by the ATCs (certified athletic trainers) about injuries.  Many players were examined and removed but not all.

Bell: Do you think the union’s desire for independent experts on the sideline to examine/diagnose/clear players is valid?

Ellenbogen: Independent experts on the sidelines would make the situation worse, unless they had a baseline exam on each player.  No one knows the players as well as the athletic trainers, period.  Having said that, some teams already have neurosurgeons on the sidelines.  Having a doc show up just for a game takes away the all-important baseline exam and continuity of care.  It would be like getting operated upon by a surgeon who did not see you pre-operatively.  Is that safer than having someone who saw you beforehand?  The baseline is all-important in making an assessment if a player is OK after a hit.

Bell: What about delayed symptoms? Is it possible this is what happened with Smith and Cutler?

Ellenbogen: Smith’s and Cutler’s symptoms both evolved as they played, according to team doctors and athletic trainers who know them best, according to the ATC.

Bell: Are there loopholes or a gray area that need to be addressed in the concussion protocol?

Ellenbogen: We are continuously working on educating all players, refs and teams about the importance of this injury.  Unfortunately, although some players are very good about reporting injuries in other players and sometimes in themselves, often a player does not realize they are concussed because they have a TBI.  We are always looking for new ways to make the game safer, working with the Competition Committee and sideline medical teams.  That is what we do after every weekend of play.