Emily Peters wanted to play college soccer so badly that when she suffered a concussion during her junior year in high school, she kept it a secret.
Two years later, after receiving a fourth concussion when a teammate elbowed her in the head during preseason practice at the University of Pittsburgh, Peters developed symptoms ranging from dizziness and nausea to impaired vision and headaches. The university forced her to leave the team, and now, at 22, she said she can't get out of bed quickly without getting dizzy, suffers headaches as often as twice a day and wonders if she'll ever fully recover.
"I try not to think about it too much, because what can I do?" Peters said in a telephone interview. "I don't know what's going to happen in 10 years or 20 years or even five."
Football head injuries get attention as retired professional players suffer long-term effects. But girls and women are more likely to suffer concussions than boys and men in comparable sports such as soccer, basketball, and baseball or softball. Females also take longer to heal and have more symptoms after being injured, according to doctors and medical researchers.
"There has been a marked increase in concussion awareness among athletes, coaches, parents, clinicians and sports administrators," said Brian Hainline, the National Collegiate Athletic Association's first chief medical officer. "However, there has been less public focus on concussion in other sports, and in particular, concussion in females. We need to be ever vigilant that there are mothers, sisters, nieces and girlfriends who may also suffer with concussion as a result of sport participation."
In the top division of college sports, there were 76,252 women athletes and 90,837 men during the 2009-2010 school year, the most recent numbers available. Schools in the top football division, the Football Bowl Subdivision, spent about $1.1 billion on women's sports in fiscal 2012, according to the NCAA's Revenues and Expenses report.
Concussions are brain injuries caused by a hard blow to the head or body. They can alter the victim's behavior, thinking or physical functioning.
The injury is sustained by the brain moving inside the skull, usually during a rapid motion that rotates the head from side to side. A male's neck is generally bigger and stronger than a female's, which provides him added protection. Females have less strength and natural ability to rotate their heads faster from side to side, which makes them more vulnerable, Tracey Covassin, athletic trainer at Michigan State University in East Lansing, said in a telephone interview.
"It's physics," said Covassin, who wrote her doctoral dissertation on gender differences and neuropsychological impairments of concussions among collegiate athletes.
Between 2004 and 2009, the NCAA's rate of concussion per 1,000 practices and games for women's soccer was 2.2 compared with 1.4 for men. In basketball, women had an average 1.2 concussions, while men had 0.6, according to college sports' governing body. Football players led the survey with 3.1 concussions per 1,000 practices and games.
Athletes get between 1.6 million and 3.8 million concussions annually in the U.S., according to the NCAA Sport Science Institute's website.
The University of Pittsburgh Medical Center's Sports Medicine Concussion Program treats 18,000 concussion patients a year, 60 percent of them girls and women, Executive Director Micky Collins said. Football, ice hockey and girls soccer send him the most patients.
"What we found is that whatever shortcomings you bring to the table will be exacerbated when you have a head injury," said Collins, 44, whose four daughters, ages 7 to 10, all play sports. "If you have pre-existing migraines, they will come out. Learning disabilities? Car sickness? Visual problems? It plays dirty and hits where it can hurt you the most."
Concussion symptoms, including amnesia, confusion, headaches, lack of balance, nausea and distorted vision, can reveal themselves immediately or not show up for hours or days, said Hainline, who formerly worked for the United States Tennis Association.
Research shows that men and boys usually suffer concussions running into other athletes such as when they make a tackle or check an opponent. Women get them when they fall to the ground or run into equipment like a ball or goal post, Hainline said.
The number of concussions tends to decline at higher levels of play.
"Players who may be more susceptible to concussions get knocked out as they move up the ranks," said Ruben Echemendia, a consultant to the National Women's Soccer League and U.S. Soccer. "Others develop better techniques and don't sustain as many concussions."
At lower levels, concussions are more prevalent than when most children's parents played, he said.
"It's true for both guys and girls," said Echemendia, a doctor. "Players are more competitive, their conditioning has improved, their speed and size and strength have improved and they have become more physical."
Peters graduated with a degree in finance and now works at Dick's Sporting Goods corporate headquarters in Coraopolis, Pa.
She loved school, but it became difficult because of her concussion symptoms, she said. They worsened with stress, and there were weeks when she'd have as many as three doctor visits and therapy to improve her vision and balance.
The symptoms, constant medical appointments and school work all weighed on her. Sessions with a psychologist helped her overcome depression and emotional issues related to her injury.
"I would have dreams of getting hit in the head," she said. "I was scared. It consumed my life because I was always at doctors' appointments with symptoms every day. It can be overwhelming."
Regular sleep, a good diet and plenty of fluids helps to alleviate the symptoms, she said, though she still can't overexert herself physically with a two- or three-mile run. Her worst moment of the ordeal was the day the university said she could no longer play soccer.
"I was extremely depressed," she said. "It was a shot to the gut."
Football concussions have been getting attention as thousands of former National Football League players sued the NFL, alleging it knew about head injury risks since the 1970s. The league denies it.
Doctors and trainers say women need to recognize they are more susceptible to concussions than men. They should start a weight program to build up strength in their neck and shoulders and they can work to improve their skills, particularly in soccer, where many young players haven't learned the proper technique to head the ball.
"Too often they just go up and have no control over their action," Michigan State's Covassin said.
Referees can help, too.
"If officials follow the rules and don't allow elbows to come up in close contact to clear out the area, it eliminates some of it," Echemendia, the consultant to U.S. Soccer said.
No helmet or other equipment has been proven to prevent concussions, said Hainline from the NCAA. Helmets prevent cuts and skull fractures, but don't stop the whipping rotation that accompanies concussions.
As soon as an athlete, parent or coach recognizes concussion symptoms, the player should be removed from the game and evaluated by a health professional, Hainline said in an interview. The NCAA has produced concussion management recommendations in its Sports Medicine handbook, plus fact sheets for coaches and athletes.
The Centers for Disease Control and Prevention website says about 75 percent of traumatic brain injuries are concussions.
Collins, who has a 24-person staff at the University of Pittsburgh's concussion program, helped develop the CDC's concussion tool kit and assisted in the development of the testing system used by sports leagues and the military to evaluate concussion severity and determine when an athlete can return to play.
He's treated professional athletes including New England Patriots quarterback Tim Tebow, Pittsburgh Penguins center Sidney Crosby, race car driver Dale Earnhardt Jr. and 2006 American League Most Valuable Player Justin Morneau of the Minnesota Twins.
Collins says one in 10 high school athletes will suffer a concussion this year and most will need more than a week to recover.
"Emily is a case that is very unfortunate," Collins said. "To be very honest, it's rare we see someone who can't get completely better. We have effective treatments and approaches now where the majority will recover fully from injury."
Peters has spoken to young female soccer players about concussions and the mistake she made playing despite her brain injuries. She said she understands how a girl can want something so much that she can't fathom the notion of pulling herself out of a game or sitting out weeks because of a bump on the head.
Her decision has cost her dearly, she said. And she never achieved the goal she coveted most: to play in a regular-season college soccer game. Now, compounding her disappointment, are the lingering symptoms that have forced her to change her life.
"It's not worth it," she said. "If you are feeling headaches, if you feel anything. It's extremely dangerous to play through symptoms. That's what I'd tell them: Don't do it."