Concussion management in professional soccer: an opinion piece

Dr. Luis Rodriguez, demonstrating his skills.

The 2014 World Cup is getting smaller in the rear-view mirror day by day, and the sporting world’s collective attention is turning to other events.  The Commonwealth Games is about to open in Glasgow; the 2016 Olympics are not far off and will, of course, occur in Brazil (Rio); and another World Cup is coming around the corner:  in a little more than a year the Rugby World Cup will kick off in England.

And for the Americans in the on-line crowd, there is the little matter of NFL preseason training camps opening at the end of this week; my beloved Packers start up this Saturday!

On the other hand, the discussion about the management of concussion at the Brazil World Cup is not diminishing.   From media like the Washington Post to social media such as Twitter–which, frankly, remains all ‘atwitter’ over the issue–the dissection of the events and the discussion of what to do next continues.  The New York Times has captured the ‘zeitgeist’ I think with its headline:  FIFA’s Dazed and Dated Attitude.

We have had several posts on this issue already.  I offer you yet another today.  I take part in a LISTSERV which includes members of one of our affiliated societies, the American Medical Society of Sports Medicine (AMSSM).  Last week, I joined in on a robust and wide-ranging discussion about issues of concussion management in soccer (apologies to some readers, since this on-line football discussion mostly involved Americans, the word that was kicked around was, indeed, soccer).  The LISTSERV discussion was so intriguing that I reached out to the participants and asked if anyone was interested in doing a guest post on this blog.  I got a volunteer!

Dr. Luis Rodriguez is an AMSSM member, a clinician and teacher, and an avid soccer player and fan.  He is the Assistant Program Director – UHS Wilson Memorial Hospital Primary Care Sports Medicine Fellowship Program, Johnson City, NY, and is a Clinical Assistant Professor at SUNY Upstate Medical University, Binghamton Campus.  He is, as well, the Team Physician for the Binghamton University Bearcats, the SUNY Broome Hornets, and the Davis College Falcons.

Concussion Management in Professional Soccer–Dr. Luis Rodriguez

According to the Nielsen company, an estimated 26.5 million people in the United States watched Germany’s extra-time win over Argentina in the final game of the FIFA World Cup on Sunday July 13, 2014. Being a huge soccer fan, I played my small part in making this the most watched soccer match in U.S. history, even though I was not rooting for anyone in particular. I also knew I was not the only Sports Medicine doctor watching of course, and this fact became pretty obvious early into the first half of an excellent soccer match (although I prefer the term “futbol” myself).

It was the 16^th minute, German midfielder Christoph Kramer was fighting for possession deep into Argentinian territory and received what was surely an unintentional (and perhaps most importantly unexpected) hit to the left side of his head and face from the shoulder of defender Ezequiel Garay. Kramer went to the ground immediately, and the ball was put out of play by Germany after a brief delay. During this time, ESPN’s English commentators mentioned he had tried to get up but went back down. Germany’s medical personnel got to him when the game clock showed 17 minutes, 10 seconds and began evaluation. 30 seconds later he was given the famous “pat in the back” that all of those who cover sports as team physicians are probably familiar with as the universal sign for: “you’re ok, now get back in there!”.

The referee did not let Kramer back in immediately, as per official FIFA rules, he had to leave the pitch since medical personnel came in to provide care. I must say, he looked quite dazed and confused to me as he was making his slow walk around the pitch waiting for permission to come back into the match.

Unsurprisingly, Kramer was substituted after roughly 15 more minutes, he was helped out of the field with a clammy appearance and a vague stare. Shortly after, the American Medical Society for Sports Medicine’s (AMSSM) group email server lit up like a Christmas tree! The general thought was that Kramer’s head injury was not managed according to the 4^th International Consensus Statement Guidelines from the 2012 meeting in Zurich (which are still up for debate as everything else in science), published in the CJSM in March of 2013. The consensus guidelines state: “sufficient time for assessment and adequate facilities should be provided for the appropriate medical assessment both on and off the field for all injured athletes”.

I would add that the expert community agrees that until such assessment has taken place, the athlete(s) should be safely removed from play and the adequate disposition is to be determined after clinical evaluation. I think these recommendations most importantly associate with the dangers of the dreaded second impact syndrome, which is perhaps the main reason the Zurich panel argues against same day return to play at any level.

By writing this blog post I do not mean to scold those who evaluated and provided care to Kramer (or to Pereira or Mascherano for that matter), but to stimulate discussion that can help the Sports Medicine community improve care for athletes. I remember thinking that it was quite ironic to see the FIFA logo in the SCAT3 that we use on the sidelines and in our concussion clinic, and yet see the media uproar caused by poor management of head injuries during the world cup. The Lancet, ESPNFC, HuffingtonPost.com and Slate.com, to name only a few, had strong words of criticism against FIFA. Clearly we are not the only ones who think we should do better, the world is watching.

This is a complex issue. As clinicians who provide sideline medical coverage we are often faced with challenging decisions, which have many variables, added stressors and even some confounding factors. Some AMSSM members think the “drama” of soccer can cloud our judgment, as players often go down to get a call in their favor or even a card for the opposing player. Perhaps Arjen Robben will get the Oscar for his fantastic diving this year, but regardless, this makes it challenging for the providers to know sometimes who is really injured. Also, it is quite easy for us to make the call from the comfort of our sofa with high-definition and instant replays, while the on-field providers struggle to obtain a history with 73,000 screaming souls around them and not always a clear idea of what exactly happened.

Also, we have to consider the weight that the coaches and player’s desires have over this matter, particularly when the stakes are so high for them. This automatically takes us to the issue of rules and regulations, as it does not seem fair to commit a team to play 1 man down at such an important stage, so that a proper head injury evaluation can take place (it should take more than 30 seconds). In my humble opinion, a possible solution would be to allow teams an emergency substitution (temporary with the option of making it permanent) for medical evaluation and care.

I also think that medical providers should have unchallengeable authority to hold athletes out of competition to decrease the risk of a more severe injury resulting from decisions made by coaches and/or players in the heat of the moment. Unfortunately, I do not expect these changes to happen anytime soon for many different reasons but, we can do our part by educating the sports community and lobbying for change. I would appreciate everyone’s comments and suggestions, cheers!

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Thanks again Dr. Rodriguez.  And to all you following us, contribute your voice to this discussion in the comments below or on Twitter @cjsmonline

We’ll have a podcast coming on this same subject very soon, so ‘stay tuned’!