PHOENIX — Despite all the rehabilitation, the headaches would not go away. The imbalance, while better, was still there. His speech improved, but vision and hearing issues persisted.

Months after the blow that caused his concussion, Rudy Ayala still had significant symptoms.

Though he loved playing football, the lingering problems, along with watching a friend suffer a similar injury, led Ayala to make a difficult decision: He walked away from football.

“I just realized the damage that can happen to your brain with a big blow like that and I didn’t want it to happen again,” Ayala said.

The NFL and NCAA have taken steps toward preventing, identifying and treating concussions in recent years. The practices used on those levels have trickled down to high schools, where coaches are getting better concussion-recognition training, limitations have been put on head to head impacts and treatment protocols have been established.

At the same time, concussions are still a substantial issue in high schools, in part because there are so many more players at that level than in the college and professional ranks combined.

The National Federation of High School Associations has guidelines for concussions, including management of athletes who exhibit symptoms and an online concussion course developed with help from the Centers for Disease Control.

But the reach only goes so far; there are just too many schools, too many players and too many variations from state to state and school district to school district to make sure concussions are being treated in a uniform manner.

“The fact that we’re talking about treatment of concussions is an advancement,” said Dr. Javier Cardenas, a neurologist at the Barrow Neurological Institute’s Concussion and Brain Injury Center. “That said, there’s clearly more left to be done.”

Inconsistencies in the availability of athletic trainers can make it difficult.

Having coaches and parents with concussion awareness is a big step, but athletic trainers have a deeper, more clinical understanding of what to look for and what needs to be done after a head injury.

Most big school districts can afford to have athletic trainers at every school. Smaller districts may have a trainer who serves multiple schools or none at all.

Nationally, about 55 percent of schools have a full-time athletic trainer, according to the National Athletic Trainers’ Association. Arizona has one of the highest rates at 60 percent and California, in part because of licensing issues, is around 20 percent.

“If there’s one thing that a school can do to improve the safety, it is to have an athletic trainer,” Cardenas said. “But that’s not always possible.”

Games have a higher rate of concussions due to the increased intensity and larger impacts, with 1.86 per 1,000 athlete exposures, according to a Journal of the American Medical Association Pediatrics study. From an overall standpoint, more concussions occur in practice, a logical progression since there are far more practices than games.

Ayala suffered his concussion while practicing the day before a game in August 2014.

A defensive lineman on Tempe High School’s junior varsity team, he was injured while tackling a teammate during warmups and the coaches sent for the school’s athletic trainer. When Ayala collapsed while trying to stand up, the trainer called paramedics and rushed him to the hospital.

“I saw him, he wasn’t looking right,” said Ayala’s mother, Teresa. “He was just acting weird and I said something’s not right with him. It was very scary.”

At the hospital, doctors ran a battery of tests and scans to make sure nothing catastrophic had occurred with the impact. The presentation of the concussion was typical, so doctors sent Ayala home.

His odyssey was just beginning.

Ayala suffered intense headaches, had problems with his hearing and vision, particularly in bright light. He also had trouble with his speech, issues with sleeping and struggled with his balance, often needing to catch himself on a wall after stumbling.

Ayala was told not to use his cellphone, computer or to watch TV for more than three months. Accommodations were made for him at school, like closing the blinds in the classroom to block out light, moving him to the front of the classroom so he could keep focused on the lessons.

Progress moved at a sloth-like pace, the symptoms lingering months after the initial impact.

“I felt like, ‘Am I going to get better?” he said. “I was really scared.”

The previous protocol for concussion treatment was rest and more rest. In recent years, doctors have taken a more proactive, multi-disciplinary approach.

From a physical standpoint, doctors can prescribe headache medicines and help patients work on their balance. They offer speech therapy and will work with patients on regaining their hand-eye coordination.

Doctors now also work on behavioral therapies, helping patients get past the irritability, anxiety and depression that can often come with a concussion. There are cognitive therapies as well, assisting patients with their short-term memory, focus and tasks like calculations or finding the right words when their minds struggle.

“Our recommendation is you can be active in your recovery aside from that initial period of two to four days,” Cardenas said. “We want them to get back to being active, healthy and normal, but still avoid injury.”

Ayala’s case was atypical.

Most teenagers will recover from a concussion in 14 to 21 days. Ayala continued to have symptoms nearly two years after his injury.

Teresa said it took about a year of working with Cardenas before she saw “my son come back.” Even then, it wasn’t until recently that Rudy was cleared to return to sports. He still occasionally suffers headaches.

“I would hate for anyone to have to go through anything like that,” said Ayala, now a senior at Tempe. “I know I wouldn’t.”

Ayala is currently a member of Tempe’s cheer squad for football games and plans to go out for the baseball team next spring.

His football career is over.