After watching youth football players do drills this fall aimed at reducing their risks of concussions, NFL Commissioner Roger Goodell told them to speak up if their "head or ankle or anything else" didn't feel right.
"There's nothing wrong with ... raising your hand and saying, 'I don't feel good,'" Goodell told kids in Virginia.
What if you're an NFL player? Beyond wanting to tough it out and play, what if you fear sitting out might cost you a starting job?
During a Nov.11 game, quarterback Alex Smith of the San Francisco 49ers told coaches and medical personnel he had blurred vision. Diagnosis: concussion.
Colin Kaepernick made his third consecutive start at quarterback for the 49ers on Sunday. Smith has been active the previous two games. Despite his struggles in an overtime loss to the St.Louis Rams on Sunday, Kaepernick remains the starter. No matter who ends the season with the job, it doesn't change the conversation ignited by the veteran's benching.
The NFL is stressing a change in culture when it comes to head injury. A year ago, the league took heat for not checking Cleveland Browns quarterback Colt McCoy on the sideline for a concussion after a brutal helmet-to-helmet hit from Pittsburgh Steelers linebacker James Harrison. It has stepped up systems in place -- including an athletic trainer monitoring the action and TV feeds in the press box -- to spot potential concussions and make sure players get evaluated.
On NFL sidelines, medical personnel follow a checklist for obvious signs of disqualification, such as headaches, nausea and dizziness. Since late last season, the league has stationed athletic trainers in the press box to monitor players for possible concussions.
Hunt Batjer, neurosurgeon and co-chairman of the NFL's Head, Neck & Spine Committee, says the mantra is medical decisions trump competitive ones. "Let's say I'm an NFL quarterback and I've realized I've had a concussion but I'm not so impaired that I can't continue playing. ... The danger of that is I could have another one before I recover from the first one, which is actually going to cost me a lot more time," Batjer says.
Late last week Smith wasn't second-guessing his decision to self-report. "No, I'm not looking back on that," he said.
He isn't sure whether his example will make other players more reluctant to follow suit.
"I don't know. It's a good question," said Smith, who was leading the league in completion percentage at the time of his injury. "I mean, that's kind of the deal with all injuries."
Former 49ers linebacker Bill Romanowski does question whether Smith made the right move. He told Bay Area radio station 95.7 The Game that a lot of guys still do play through concussions.
Julian Bailes, Chicago neurosurgeon and co-founder of the Brain Injury Research Institute, heard Romanowski's take.
"We thought we were making progress on the change in the culture, and now the fact that this guy, Alex Smith, lost his job once again brings up the issue that the culture is still in question," Bailes says.
The NFL is the target of federal lawsuits by more than 3,700 former players who allege that for decades the league failed to protect them from concussions and their long-term effects. Today, researchers in Boston will release a report that includes the cases of 33 former NFL players diagnosed after their deaths with brain damage linked to repeated concussions.
A player could be faced with a choice: job security over the short haul vs. quality of life over the long haul.
Denver Broncos wide receiver Brandon Stokley, in his 14th NFL season, says players understand the potential job ramifications.
"I think you always have that kind of feeling of -- not necessarily that you're going to lose your job -- but guys still hide them, they'll play through them," Stokley says.
Stokley estimates he has had about a dozen concussions going back to college. He says that when he was younger he would play through lesser hits. He says he missed time with the Broncos in 2008 and the Seattle Seahawks in 2010 after being diagnosed with concussions. "Everyone's awareness has changed," he says. "You realize there could be repercussions down the road."
Bailes was a sideline physician for about 25 years with the Pittsburgh Steelers and West Virginia University football.
"I would say it's harder to hide one, especially one of any great significance," Bailes says.
But there are 22 players on the field. So having individual players take responsibility for themselves remains a factor.
"I really think there's been a substantial culture change that's occurred over the past two to three years that the players understand there is a difference between a thigh injury and a brain or spinal cord injury," Batjer says.
During a Nov.18 game, eighth-year linebacker DeMarcus Ware of the Dallas Cowboys went to the sideline late in the third quarter for a concussion assessment and returned to play in the fourth quarter. Ware says a concussed player is not hard to spot: "You know something is a little bit wrong with a guy when he's a little foggy; he's just walking around, his demeanor, how the guy's acting."
Broncos defensive back Champ Bailey, in his 14th NFL season, says he'd report any issue, especially if it involved his head. "I'm old. I wouldn't be reluctant," he said.
How about for a young guy trying to earn his place? "I think in some cases guys will be reluctant to say, 'I'm a little dizzy,'" Bailey says.
"Because it's our jobs."
Contributing: Jarrett Bell, Lindsay Jones
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