Sarah Carlton smiles through her pain in the photograph from 2008.
She’s 11. She collided with an opponent going up for a ball, then blacked out as she hit the ground. A referee asked what happened. Sarah remembers thinking that she didn’t know.
Still, she finished the soccer game, put an ice bag on her head, then played again that afternoon and the next morning – less concerned about the hit she suffered than about helping her team win the tournament.
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Sarah was tough, a quality her coaches always admired. If it were up to her, she was never coming out of a game.
But there were many more hits to the head as she became a high school star on a path to play at Davidson College like her sister. Headaches wouldn’t stop. Many nights she would stare at a computer screen, struggling to write a paper already overdue.
Now, seven years later, Sarah looks at the photograph and wonders:
How many concussions have I had?
Playing through pain
Concussions remain one of the great mysteries of sports, often going undiagnosed because there usually is neither blood nor other obvious physical clues that something is wrong.
Concussion awareness has increased over the past decade. When concussions are recognized and properly treated, athletes usually recover in weeks. Experts say the benefits of playing sports far outweigh the risks, especially when so many people suffer from obesity, diabetes and heart disease brought on by inactivity.
But we still too often act in ways that make head injuries worse.
Some people still believe that an athlete has to lose consciousness to suffer a concussion. One can be caused, though, by any jolt that makes the head and brain whip rapidly back and forth, or even by what appears to be a mild bump.
Athletes who get hit in the head don’t always ask for help. Instead, they sometimes stay in the game and play through pain, risking further injury so they won’t lose their spot in the lineup or let down their teammates.
Players, coaches and parents, especially in youth sports, often don’t know concussion warning signs. Medical treatment isn’t always sought when needed, and athletes sometimes come back from a concussion too soon, risking more serious injury or even death from a condition called second-impact syndrome.
When Sarah Carlton was growing up, we knew even less.
‘Aggressive in the air’
In 2012, when Sarah was 15 and in ninth grade, Dr. Robert Cantu, a leader in sports head injury research, said that the country was in the midst of a concussion crisis. It wasn’t just football players getting hurt. Girls’ soccer was reporting the second-highest rate of concussions among high school sports.
By then, Sarah was all-state at Porter-Gaud High School in Charleston, a leader on the field though she was one of the team’s youngest players.
Her coach, Daniel Jordan, says Sarah had a unique talent: “She was aggressive in the air.” A skilled defender, Sarah was taller than most of her peers. She would leap and thrust her head forward to knock the ball away on defense, or head the ball toward the goal off a corner kick, a signature move of Abby Wambach of the U.S. World Cup team. A diving header can be one of soccer’s most exciting plays, and also one of the most dangerous.
“If I could score, or keep someone from scoring,” Sarah says, “I would put my head wherever I needed to.”
In a March 2012 high school game, Sarah was kneed in the right temple. She was dizzy, confused, and saw black splotches, but played on.
That night, she felt nauseated. Her head throbbed – the area where she was hit was swollen and spongy. The next day, a pediatrician noted that Sarah had been in the office with a soccer concussion a year earlier and told her to take some time off.
Sarah was cleared to play in April. Prior to that, on one clinical test, she had rated her post-concussion symptoms lower than they actually were, hoping to return to play sooner than if she told the truth.
In a May playoff win for Porter-Gaud, she was elbowed on the same side of the head. The school’s athletic trainer didn’t attend away games, so she was not there to help diagnose the injury. Thinking it was only a black eye and not a concussion, Sarah played two days later in the state championship.
“I probably shouldn’t have played,” she says now. “But sitting out would have killed me.”
‘No headers on punts’
Sarah looked forward to a break from soccer on a summer trip to the Bahamas. But there, she began to have migraine headaches – while snorkeling, riding in a boat, even lying on the beach.
She began practicing with her club team in August 2012. But headaches became more frequent and more extreme as her sophomore year began. She missed class often, going home at noon to a darkened room. She struggled to complete her work, and her grades suffered. She stopped playing club soccer.
Her mother, Elizabeth, began to wonder whether the headaches were connected to the hits Sarah took in the spring – neither the family nor Sarah had a history of migraines. She also was suffering from fatigue, severe mood swings and depression, all post-concussions symptoms.
The school athletic trainer, Laura Richins, advised the family to go to a head injury expert.
Over the next year, Sarah would see three head injury specialists and take tests that ruled out more serious brain injury such as bleeding or structural damage. Her parents say they followed the doctors’ advice.
Dr. James Bumgartner, a Charleston neurologist, treated Sarah. “She had severe throbbing headaches that were clearly migrainous,” he said. “They were very frequent and impacting her ability to function.”
Sarah returned to her high school team in the spring of 2013, attempting to play a more conservative game. She wore a concussion head band to help cushion blows. She tried to limit headers but struggled to hold back.
Jordan, her high school coach, says Sarah was the most intense player he had ever coached on either his boys’ or girls’ teams, and that it was hard for him to take her out of a game.
“I didn’t realize the impact that concussions could have on a player’s life,” Jordan says now. “Having played soccer myself, and also being aggressive in the air, it was naive on my part.”
Despite all that Sarah had been through, she was playing her best soccer. That summer at camp, she so impressed Davidson women’s soccer coach Greg Ashton that he took her aside and told her that there would be a place for her on his team. This had been her dream since age 12. Each summer, she would pack a suitcase full of Davidson T-shirts for camp and pretend she was headed off to college to become a Wildcat.
Everything, Sarah thought, was falling into place.
In the fall of 2013, now a junior, Sarah suffered another hit to the head in a club game, though it took a hamstring injury to end her season early.
The headaches became crippling. She started associating soccer with pain. She began to dread the thought of playing at Davidson.
Depression had led her to a therapist, who told her two truths that changed her life: You don’t have to keep playing. If you don’t play, you’re not letting your teammates down.
“It was just nice to have someone outside of the environment, the club soccer world or even my family to just kind of beat it into me that I didn’t have to keep doing this to myself,” Sarah says now.
One night in January 2014, she came down to the kitchen. Her mother mentioned hearing again from a New Orleans club soccer coach about Sarah playing with his team at a tournament in March.
“I don’t think I’m going to be able to do that,” Elizabeth recalls Sarah saying. “I’ve been meaning to talk to you …”
Then Sarah told her mother that she was leaving the game for good.
Elizabeth was shocked, but immediately supported Sarah’s decision. Privately, though, she worried that quitting soccer would leave such a hole in her daughter’s life that it would make her even more depressed.
Trying to recover
Spring came. For the first time since she was 5, Sarah was not on a team. She would later write in her college essay: “My decision gave me relief, yet it saddled me with a new question ... Who am I exactly, without soccer?”
Sarah offered to help at high school practice, then had to tell the coach she couldn’t; her feelings about the sport were too raw.
She had spent so much time in her room with migraines, she had cut herself off socially. But she pushed herself to get out with friends again and even tried out for the school play. It was “West Side Story,” and she got the part of Anybodys – a teen who is neither a Shark nor a Jet but who would do anything to be in a gang.
Sarah struggled more with schoolwork as the year went on. In the fall, her AP U.S. History teacher had written on a paper: “WOW!!! This reminds me of why I always thought you to be one of the most capable of my juniors.” But by March, she couldn’t keep up and had to drop the class.
She missed deadlines. When a teacher moved a deadline back, Sarah thought: If the migraines stop, I can do that. If not, I can’t.
A new sport
Sarah took the ACT college entrance exam in April 2014 and was disappointed with her score – a 26, which put her in the 83rd percentile. She had struggled to focus during the timed four-hour test and went home to bed when it was over.
But her time away from soccer, and a reduced class schedule, helped her finish her junior year.
She felt better as her senior year began. In September 2014, she took the ACT again. Able to focus more this time, her improvement was dramatic – a 32, which put her in the 98th percentile.
I hated to see someone who cared so much... have to leave the game because of something that may have been avoidable if we knew more.
Porter Gaud coach Daniel Jordan
On the advice of her neurologist, she had started running. She missed competing and being on a team. So she decided to try cross-country. Her new coach, Hugh Knight, was struck by her will to win. He became confident that if anyone was just ahead of Sarah in the last 100 meters, she was going to run them down. She improved each meet and was named team MVP.
By then, some classmates who knew about Sarah’s head injuries had begun to ask for advice. She remembers a friend who suffered a concussion in spring football asking: “Do you still get headaches – like sometimes, you don’t feel like yourself, you just feel off?”
Maybe, she thought, it would help others if I shared my story.
Porter-Gaud encouraged public speaking and students gave “senior spotlight” speeches during morning assembly. She scheduled hers for March 2015.
She wanted to make two points: Your health is more important than sports. And no matter how dark things seem, you can always get better.
She worried how her classmates would react to such a personal story. Her parents, sitting in the audience of about 300, were nervous, too.
“Good morning. My name is Sarah Carlton,” she began. “... January of 2014, I decided to quit soccer forever.”
She struggled with the first sentences, then fell into a confident rhythm: “I was suffering from debilitating headaches and crippling depression that made me unable to be an active participant in my own life.”
Displayed behind her were photographs her mother had taken: Sarah at 8, hitting the ground after a slide tackle.
The photograph of her at 11 with an ice bag.
Sarah at 15, in a sequence of photos: About to crack heads with another player. Standing in pain. Then, for one of the very few times, leaving the game after an injury.
Sarah told her classmates how difficult soccer was to give up – and why she finally did.
“Some of y’all haven’t experienced a debilitating migraine ... It’s the worst pain I have ever experienced. You know when you slam your fingers in the car door it’s impossible to stop thinking about the pain because it throbs with every heartbeat? Well, imagine slamming your head, again and again, in the car door.”
It was heartbreaking the whole time, thinking of the trajectory of the story and wishing, ‘Why didn’t I see this before?’
Elizabeth Carlton, on watching her daughter’s speech
She talked about depression:
“I thought of myself as worthless... Going through my daily routine was like trying to tread water with someone pulling you down ... After years of pretending that I was OK, pretending that I was getting better, I confronted myself with the fact that I wasn’t getting better.”
I got help, she said, and told her classmates: Help is available for whatever you’re going through.
Then she thanked those who supported her.
“Most of all,” she said, her voice breaking, “I want to thank my dad and my mom. They are the best people that I know, and I don’t know who I would be without them.”
She finished and there was silence in the room. Then, students and faculty rose in an ovation. Students came forward to thank Sarah, and she heard from people for days.
‘Take the time off now’
Sam and Elizabeth Carlton struggle with what they could have done differently to help their daughter. Until hearing Sarah’s speech, Sam said, he didn’t truly understand all that she had gone through.
“I know people are going to read this article and they will say these parents are really dumb,” Sam Carlton says. “But we’re not dumb. I’m sure we’re not the smartest ... Still, until she gave that speech, I didn’t understand the depth of it. I really, really did not understand.”
Sarah’s family believes she had four concussions, but there might have been more. Sarah, 18 now, still has occasional headaches, though not nearly as often nor as severe.
She wants others at risk to understand what’s at stake: “If you think that you might have had a concussion, or you injured yourself, or you’re not feeling yourself, it is worth it to take the time off now and not have to take the rest of your life off later.”
Sarah never applied to Davidson. Going there without playing soccer would have been too hard. Instead, she started school in August at Sewanee, a private college in Tennessee.
While visiting the school last October, she had stopped by cross-country coach Jeff Heitzenrater’s office to ask if there might be a place for her on his team.
Heitzenrater told her there was. He remembers being excited about Sarah’s potential. In notes, he wrote: “A soccer player with too many head injuries who took up running cross-country ... Has improved over two minutes just this year. Still lots of room for improvement.”
Sarah met some members of the Sewanee cross-country team that day. In conversation, she mentioned she used to play soccer. Another runner said she did, too, until a concussion and headaches caused her to quit the sport and take up cross-country.
“To see her successful,” Sarah says, “was like seeing myself in a couple years.
“And I liked what I saw.”