SANTA CLARA -- Facing a flood of lawsuits from former players and confronted by troubling new brain research about the long-term toll of head trauma, the NFL is doing more to protect players.
But as Alex Smith found out, at least one aspect of football culture remains unchanged: Once you step off that field, there's no guarantee you'll be back.
The 49ers quarterback did all the right things after his Nov. 11 concussion, reporting his blurred vision to the training staff and remaining on the sideline until he could pass the league's increasingly strict protocol for returning to play.
He was sidelined for a game-and-a-half, which proved to be just enough time for Colin Kaepernick to move in as the 49ers' starting quarterback.
At a time when the NFL is urging more respect for brain injuries, Smith's benching raises a question about fairness -- and makes some wonder whether a dangerous precedent has been set considering the league needs the cooperation of players to better diagnose concussions.
"That's pretty profound stuff," Hall of Fame quarterback Steve Young, whose career was ended by a concussion, told KNBR radio. "The league has this protocol for head injuries that they really want to gain some momentum. And now (a player) is going to lose his job over it. Probably not a good fact going forward for the head-injury efforts."
Former running back Dorsey Levens, one of almost 4,000 retired players suing the NFL over head injuries, added in a phone interview: "If you're not on the field and performing, they will find somebody to replace you. And that's just the cold, harsh reality of the NFL. At the end of the day, it's 'What have you done for me lately?' "
Bill Romanowski, a former linebacker for the 49ers and Raiders, took things a step further by blaming Smith for opening his mouth. —'Careful' in the NFL means losing your job," he said on 95.7 The Game. "And that's what this did for him."
Did Smith get a raw deal?
Not according to a range of doctors, concussion experts and former NFL players contacted for this story. While they sympathize with Smith's frustration, they say it's a small price to pay.
"He wasn't burned. The 49ers might have saved his life," said Neil Chasan, a physical therapist and the director of the Sports Reaction Center in Bellevue, Wash. "The truth is: He wasn't ready to play. And if he had taken another hit to the head he might have died."
As Dr. Hunt Batjer, co-chairman of the NFL's Head, Neck and Spine Committee, said in a phone interview, "You play through pain, but you do not play through a brain or spinal injury. You're risking a permanent change and even death."
Smith, 28, was on a roll before taking a blow to the head during the first half of a game against the St. Louis Rams in San Francisco. In the eight quarters before he was hurt, he completed 32 of 35 passes for 385 yards with five touchdowns and one interception. Smith's passer rating during that span was a stellar 140.2.
Smith has been benched plenty of times over the course of his tumultuous eight-year career with the 49ers, but this time it smacked of betrayal. During a glum, clenched-teeth session with reporters recently, Smith said: "I feel like the only thing I did to lose my job was get a concussion."
NFL Commissioner Roger Goodell weighed in on the matter Thursday night during a visit to the O.co Coliseum in Oakland. Asked about the message Smith's benching might send to the rest of the league, Goodell said: "That it's about safety first. ... Competitiveness is not going to be the No. 1 driver. It's going to be safety. And that when someone gets injured, those are medical decisions and they have to be made by the medical professionals. The football decisions are made later when the player is healthy, and that's what the 49ers have done."
Levens, a Pro Bowl running back who played from 1994 to 2004, noted he got his starting job with the Green Bay Packers because running back Edgar Bennett suffered an Achilles injury -- and lost it when his own knee problems created an opportunity for Ahman Green.
"You saw the Peyton Manning situation last year. If his job is not safe, then absolutely nobody's job is safe in the NFL -- nobody's," Levens said, referring to the quarterback whose neck injury ended the future Hall of Famer's tenure in Indianapolis.
"And players are aware of that. You can give them all the information we have about concussions and the long-term ramifications -- early onset Alzheimer's and dementia and suicide," he said.
"With all that information being readily available to guys, they still don't care. You know why? Because they want to play football. And the only way to play football is to be on the field."
Because concussion symptoms aren't always easy to see, coaches and medical staff members sometimes rely on players' self-reporting. The NFL has created rigorous neurological safeguards to prevent players from returning too early.
Several doctors noted the risk of second-impact syndrome in younger players. Players may be dramatically more susceptible to future concussions if the initial injury is not properly treated.
"The culture of football is changing. Teams are very cognizant of not putting a player back before he's ready," Dr. Teena Shetty, a neurologist for the New York Giants, said from her office at Hospital for Special Surgery in New York. "If (Smith) were my patient, I'd say the right thing was done for his long-term health."
A number of players, however, have echoed Romanowski's statement that they would rather lie about their symptoms than risk what happened to Smith.
"You have to have a fight in you, hunger in you and that dog in you," former Pittsburgh Steelers running back Willie Parker told the Pittsburgh Tribune-Review last month. "If you have a concussion, why would you tell? Why would you say something?"
Experts say this is why: The Boston University group announced Monday the discovery of 28 new cases of brain damage in deceased football players -- including 15 who played in the NFL.
Chris Nowinski, co-director of the Boston University Center for the Study of Traumatic Encephalopathy, was the co-author of a study published in the December issue of the medical journal Brain. It found that among 85 individuals with a history of repetitive head trauma, autopsies showed 68 had chronic traumatic encephalopathy, a condition linked to dementia, memory loss and depression.
Former Cal offensive lineman Ben Lynch, who played four seasons with the 49ers and now is a board member of the California Concussion Coalition, said Smith's scenario "really highlights the situation."
"We all know football is a game of attrition. But Alex's career may have completely changed on one play, and nobody yet can really say what the long-term effects would be if he had kept playing," Lynch said. "We're still so far behind in brain research."
Contact Daniel Brown at email@example.com. Contact Mark Emmons at 408-920-5745.