The recent head collision in a match between Wolverhampton Wonderers player Raul Jimenez and Arsenal’s David Luiz, again brought attention to concussion protocols in football. Jimenez suffered a fractured skull and required surgery after the accidental collision, whilst Luiz played on with a heavily bandaged head but did not reappear after half time.
It has been a hot topic for a number of years, and concussion injuries have stopped players’ careers including Ryan Mason who played for Hull City and Tottenham Hotspur. There are now calls for the football governing bodies to bring in concussion substitutes. Whilst this blog will focus on football, the current concussion injuries and discussions in Rugby cannot be ignored. I will look at the current guidelines in place from the FA, UEFA and FIFA in relation to concussion and the call for change to ensure improved better management and care of head injuries.
What is concussion?
Concussion is defined by the NHS as ‘a temporary injury to the brain caused by a bump, blow or jolt to the head’. Symptoms can include:
- Loss of consciousness;
- Confusion;
- Nausea and Vomiting;
- Dizziness;
- Changes in vision;
- Loss of balance;
- Memory loss
In a footballing context, concussion is likely caused by a clash of heads or a heavy fall. The NHS also advises that symptoms can appear immediately or any time after the initial injury and a concussed player may still be standing up and may not have fallen to the ground after the injury.
Football Concussion Protocols
The FA
The governing body of football in England issued comprehensive concussion guidelines in 2019 in discussions with an expert panel, for all levels of football, for management of head injuries, and are updated on based on new research into the area of concussion. The guidelines includes advice about recognising concussion/head injuries and what to do in such situation.
The guidelines note that ‘any suspected concussion, must be immediately removed from the field of play, and not be allowed to return to play that day.[1]
The FA also has Return To Play Guidelines following concussion incident. In an elite capacity, the minimum period of time to be allowed to return to play is 6 days, and for children this is 12 days, for the least severe concussions, At a non professional level, the standard pathway is 19 days for adults, who must have returned to work/education before starting training/physical activity and 23 days for children not in an academy elite programme. The overriding advice from The FA is ‘if in doubt, sit them out’ for players affected by a head injury.
The Professional Footballers’ Association also do support the FA and have also offered an education programme to help raise awareness amongst players of this issue.
The SFA
Similarly to their English counterparts, the Scottish Government and sportscotland, came together to produce a single concussion policy for all sports, grassroots to elite for coaches, officials, parents and athletes.
The guidance remains the exact same; ‘At all levels in all sports if an athlete is suspected of having a concussion, they must be immediately removed from play.[2]
UEFA
UEFA’s concussion protocol was implemented in 2014 for all its competitions. One of the key elements in this procedure was the advice that ‘in a suspected concussion, the referee should stop the game for up to three minutes to allow a player to get treatment. A player will only be allowed to continue playing on specific confirmation by the team doctor to carry on’. The reoccurring question that is constantly asked, is can a team doctor make a genuine concussion assessment in three minutes?
One of the most notable incidents was Jan Vertonghen’s head collision with Tottenham Hotspurs teammate Toby Alderweireld in the 2019 Champions League Semi Final v Ajax. After his three-minute assessment on the field by the team doctor, Vertonghen was allowed to continue, however a short time later had to be helped off the pitch after appearing to become unwell. This clearly highlights the three-minute assessment does not fully consider the concussion risk.
In 2019, UEFA launched a concussion awareness campaign, and UEFA Medical Committee discussed that the three minutes granted by the current concussion procedure for team doctors to assess on the pitch a potentially concussed player may be insufficient. With such a limited amount of time, doctors could be subject to excessive pressure from players and team officials. This also resulted in UEFA immediately putting up posters to remind match participants to respect the decision of the team doctor.
Additionally, UEFA also provided a medical video review system to all teams playing in the finals of the UEFA Champions League, UEFA Europa League, UEFA Women’s Champions League, UEFA Super Cup and UEFA Nations League, which allowed doctors to review live match footage and assess potential concussion incidents should they occur.
FIFA
FIFA did implement a new protocol for head injuries following the 2014 World Cup. It included the following:
- A new education program for team doctors, coaches, referees, officials and players;
- Giving the referee the ability to stop the match if a head injury is suspected;
- A 3- minute, maximum stoppage for medical staff to complete an on-pitch assessment
- The referee will only allow the player to continue if the team doctor, who has the final decision, gives authorisation;
- Additionally, in February 2018, FIFA implemented in game video review of concussion incidents where a member of medical staff could assist the primary Doctor in diagnosis via video review.
On FIFA’s own medical network platform, it explains ‘the primary focus of the initial on-pitch assessment of a player who has sustained a head trauma during training or match play is to assess the player for concussion or a more severe head or cervical spine injury.’ It is not the case that even if a player shows a sign of concussion, they must be removed from the field of play, which is different from other sporting organisations such as rugby or the NFL, rather the guidance suggests players ‘should be removed’. FIFA also provides Return To Play advice following a concussion, similarly to the above governing bodies. Six days is the minimum required in the criteria, but this is not set in stone and there is no authority to enforce it. In the World Cup 2018, a Moroccan player was allowed to play against Portugal only five days after a concussion.
Furthermore, FIFA have two additional tools to help with head injuries assessment, Concussion Recognition Tool (CRT5) for non-professionals, and Sport Concussion Assessment Tool (SCAT5), for medical professionals. The latter tool cannot be performed in less than ten minutes, which is seven minutes more than the guidelines would suggest is adequate time to check for concussion.
As the international governing body of football, the FIFA guidance at the moment is a bit vague. As the lawmakers in the sport, the above rules are not enforceable and some may argue what is the point in having the guidance if it is not being followed. This has understandably drawn a lot of criticism and concern, especially as other sports have addressed this issue
Concussion substitutes
In November 2020, it was reported that trials for concussion substitutes are set to begin in English football next season. A final decision was made on 16th December 2020 by the International Football Association Board (IFAB) confirming that the trial will go ahead with additional permanent substitutions for actual or suspected concussion as of January 2021. But is this too late? Whilst it is understandable, things to take time to be implemented, this debate has been going on for years and years, and still nothing has really been done. The FA welcome this decision, but it is understood that the Premier League are waiting to see the detail of the concussion protocol before making a decision. However, the joint board of the the Women’s Super League and Women’s Championship have agreed to back the concussion trials as well. And it goes without saying, that all the other national governing bodies should be on board with this development.
Brain Injury charity Headway has voiced concern that this is not coming into force until next season, and said ‘Concussion is hard to diagnose and needs a degree of honesty from the player, but with a temporary substitution allowed – which of course would turn into a permanent substitution – it avoids the risk of a snap judgement’.
The new rule to be implemented would allow temporary substitutions so that the injured player can go off the field and have a proper medical assessment, but not under the time constraints currently in place. And if the player can no longer continue, then the temporary player will remain on the field of play. It is important to note, that concussion substitutions are already successfully in place in Rugby, Cricket and the NFL.
Conclusion
Whilst steps have, of course, been taken to make head injuries safer within various governing bodies introducing concussion guidelines, and now IFAB’s recent decision on permanent substitutions in early 2021, is a start. Accidents like the Raul- Jiminez clash will happen in football, but procedures need to be put in place to successfully manage concussion injuries. It has caused an on going headache for years, and the welfare and safety of players is paramount, therefore it is important this is no longer overlooked.
[1] https://www.thefa.com/get-involved/head-injuries-in-football
[2] https://sportscotland.org.uk/clubs/scottish-sports-concussion-guidance/
A Sporting Insight 