Head Injuries in Sport - who's in charge?

The World Cup concussion debacle, a stark reminder of the problem

This summer's World Cup has brought the dangers of head injuries in sport to the forefront, as an international TV audience witnessed serious incidents of concussion where nobody took control of the situation as to do what is best for the sporting professional.

Firstly Uruguay's Alvaro Pereira was knocked unconscious for a full 15 seconds but argued with his team doctor and was allowed to play on. Then Germany's Christoph Kramer was also allowed to play on after a serious blow to the head, before eventually being replaced. Having crashed heads with a Dutch player, Argentina midfielder Javier Mascherano spent all of two minutes on the side lines before medical professionals and coaches allowed him to play on.

The role of referees when players are injured seems equally confused: while the German midfielder Schweinsteiger was promptly sent off the field by the referee when he sustained a cut to the cheek, officials fail to take definitive action when a player has sustained an injury to the head. Perhaps the lack of a physically obvious injury, such as a bleeding cut, impacts the seriousness with which head injury is dealt with. It is essential that greater clarity is achieved as to who is ultimately responsible when a player is injured on the pitch.

From the several instances of head injuries suffered in the World Cup it appears winning the game is currently trumping common sense and a basic duty of care to all players.

A pocket concussion guide is not enough!

FIFA has held a number of international conferences on the issue of concussion in sport, attended by various sporting bodies such as the IRB, the Equestrian Federation and the International Olympic Committee.

One outcome of these conferences has been the development of a pocket concussion recognition tool which is designed to assist anyone involved in sport to recognise and effectively treat concussion and head injury. It is not clear how widely available this guide is, or whether it is utilised, particularly at grass roots level (or indeed at international level).

Without properly enforced sanctions a pocket guide simply isn't worth the paper it's written on.

Head injuries in football aren't going away...

These conferences do not appear to have achieved much in the way of action on the pitch. Take the example of Hugo Lloris, playing in goal for Spurs in November 2013. He was accidentally kneed in the head by Romelu Lukaku of Everton. He was assessed by medical staff and his manager and allowed to play on, despite the fact that the team had a fit replacement on the bench.

A similar incident occurred between Manchester United defender Phil Jones and Wojciech Szczesny, goal keeper for Arsenal also in November 2013. Again, despite a nasty clash of heads and a visible wound above his right eye, Phil Jones was cleared to play on during the match and was also cleared to meet his England Team obligations soon afterwards.

There appears to be no set protocol given that Wayne Rooney was then ruled out of playing following a head injury sustained during training back in August 2013, which, by coincidence was with fellow player Phil Jones.

At the end of the day footballers are employees and the team therefore has exactly the same duty of care as any other employer. It's extraordinary to witness injured players being treated in such a negligent fashion and in front of millions worldwide.

There must be a clearer chain of command and clarity as to where the buck stops when it comes to deciding whether a player plays on. Debatably this decision should come from an independent medical professional and be enforced by the referee and fourth official. A referee has the right to remove a player off if he is bleeding, surely a player suffering a suspected head injury must be afforded the same level of care.

It is essential that FIFA and the FA gets on top of enforcement and stops football stumbling into a potential crisis.

Spencers Solicitors Serious Injury Team

More worryingly, there is no cross sport consensus about how to effectively deal with the risk of concussion, how to identify it and how to reduce the risk to participants to the bare minimum. But let us take a look at what procedures are in place in other sports.


Dangers of playing at grass root level - 14 year old boy dies from Secondary Impact Syndrome

Following the death of his 14 year old son Ben Robinson, Peter Robinson has campaigned extensively throughout the UK to raise awareness of the symptoms and risks associated with concussion in rugby. His hard work has resulted in a leaflet campaign in Scotland to increase awareness amongst players, coaches and referees regarding the symptoms and dangers of concussion.

On 29 January 2011 Ben was playing rugby representing his school in Northern Ireland; he was involved in a number of heavy tackles during the match and was checked for concussion three times during the course of the game. Towards the end of play Ben collapsed on the pitch, he was taken to hospital but never regained consciousness; he later died as a result of Secondary Impact Syndrome.

Sadly, an apparent lack of knowledge and information in rugby in relation to concussion appears to be continuing. We are currently handling a live case involving a 17 year old young man who was concussed in a youth match, yet allowed to play just a week later after no medical checks. He collapsed during the second match after suffering a traumatic brain injury.

Being unable to play doesn't make you a wimp

As with the tragic example of Ben, we've had first-hand experience of grass roots rugby players who have played on despite suffering concussion. From our experience there is a deep seated culture that if you complain of suffering a blow to the head or of concussion your chances of retaining your place on a team will be diminished. This leads to a lack of medical intervention and increased incidents of injury. Attitudes towards concussion in rugby need to change, and whilst the professional sport is taking steps to raise awareness and increase safety, it is important that this change of mind set is filtered down right to grass roots level if we are to avoid further tragedy like that of Ben Robinson.

Rugby Board member resigns over controversial rule changes

Rugby has been the subject of much debate recently as new guidelines for dealing with concussion have been introduced. These rules have proved to be controversial and have resulted in the resignation of Barry O'Driscoll from the International Rugby Board (IRB) medical committee.

It is estimated by the RFU that concussion is the most common injury in the professional game with 5.1 instances of concussion for every 1000 hours of play.

Players assessed to be deemed fit to continue

The IRB have recently introduced the Pitch-side Concussion Assessment, or 'the five-minute test'. During a game, a test can be requested by a team doctor or referee if they suspect concussion.

A substitute comes to the field whilst the injured player is taken off the field to a medical room to be assessed for head injury symptoms. The player is then asked a series of questions such as 'where are we' and 'who was the last person to score' etc. The player is also subjected to a balance test similar to that used to test drunk drivers.

Questions that are asked in the five-minute test:

  • What venue are we at today?
  • Which half is it now?
  • Who scored last in this game?
  • What team did you play last week/game?
  • Did your team win the last game?

If the player gets one question wrong, has four balance errors and the presence of one of more symptoms of concussion the player is removed from the game, otherwise he is allowed to return to play. The new rules have had a mixed reception with some suggesting that five minutes is nowhere near sufficient to assess the severity of a concussion, whilst others suggest that the new off pitch assessment has resulted in a significant reduction in the number of concussed players returning to the field by 25% so there is evidence that the new system is working.

Perhaps this system could be adopted in football too, despite the mixed reception received in Rugby, the Pitch-Side Concussion Assessment would at least introduce some consistency as to how referees and team officials deal with the issue, which at present appears to be missing.

How do different sports deal with head injuries?

Surprisingly there is quite a disparity between various sports as to how each protect and deal with participants from suffering head injuries. So I want to take a look at some of the major sports, the guidelines they have to handle concussion or head injuries, and what we can learn from the tragic instances of when things go wrong. Ultimately we want to highlight the need for all those involved in sport, at amateur or professional level to take the issue seriously.

Formula One

Once a base line assessment is completed, when a driver in Formula One is involved in a collision they are required to re-sit the base line test and their results are compared as a scientific way of assessing whether they have suffered a concussion. This objective test immediately removes the possibility of the participant having the option of saying there are OK in order to continue racing when in fact they are not.

Horse Racing

Similarly in horse racing, jockeys are required to undergo a baseline cognitive test before they are issued with a licence to race. Following an incident which could give rise to concussion the jockey must re-sit the test and the results compared.

A comprehensive medical database is also used to keep details of incidents including those during training. An independent specialist medical opinion is required in cases of serious head injury, unexplained loss of consciousness, subarachnoid haemorrhage or intracranial haematoma before they are deemed fit to race.

However if there is a single seizure immediately after a concussion there will be no suspension.


Boxing is a sport inherently known for its risk of head injury, and as a result the rules and regulations surrounding participant safety are stringent.

A pre competition medical examination is compulsory and the boxer will not be allowed to compete unless he is deemed fit by the medical practitioner. Each boxer has a passbook in which the results of their examinations are recorded so comparisons can be made to earlier assessments.

The medical examination consists of a physical examination checking form but also includes balance tests and examination of cranial nerve function. Trained doctors must be on hand to deal with concussive incidents during a bout and an evacuation procedure is set up before any tournament in case emergency care is required. Following a bout each boxer must undergo a further medical examination. This includes an assessment of mental orientation and status, if any issues are detected a more detailed examination is carried out.

In addition to these safeguards, there are strict rules about when a boxer can return to competition after a concussive episode. If there is a single occurrence of knockout, or the referee stops play due to blows to the head then the boxer may not box or spar for a period of at least 30 days.

If there is loss of consciousness for less than one minute the recovery period must be at least 90 days, and if the loss of consciousness is for more than one minute the period of rest is at least 180 days.

If a boxer suffers three knockouts from head blows within a 365 day period s/he will not be allowed to box or spar for one full year following the third occurrence. Once the rehabilitation period has passed the boxer must obtain a certificate of fitness from his physician or a neurologist before they can compete, preferably with an MRI scan.

Note boxing rules from International Boxing Association medical handbook 8th Edition 2013

Comparison on how different sports deal with head injuries

Sport Pre-incident Procedure Post incident procedure Incident recording Official medical reviews
Boxing Compulsory medical examination by medical practitioner before competition, covering physical and mental health, before being allowed to fight. For every tournament trained doctors must be on hand to deal with concussive incidents, and evacuation procedure must be established prior. Strict rules on when a boxer can return to competition after concussive episode. Loss of consciousness for under a minute = 90 days, and over a minute = 180 days. If 3 knockouts are sustained in 365 day period then must not box for full year. Each boxer required to have passbook in which results of their examinations are recorded, so comparisons can be made to earlier assessments. After incident rest period, boxer must obtain certificate of fitness from physician or neurologist before they can compete, preferably with MRI scan.
F1 Racing Compulsory 20 minute base line cognitive test measuring memory, reaction time, mental speed and information processing. Required to re-sit test so results can be compared to base-line test as a scientific way of assessing likelihood of concussion. Compulsory rest period after concussion, with medical assessment required before re-entry. No Data Return after concussion must be cleared by certified medical professional.
Horse Racing Compulsory 20 minute base line cognitive test measuring memory, reaction time, mental speed and information processing. Required to re-sit test so for comparison to base-line test as a scientific way of assessing likelihood of concussion. Minimum 7 day rest, but must be completely symptom free before undergoing 2 separate medical consultations, with neuro-psychological tests reviewed by clinical psychologist and compared to base line results. Comprehensive medical database to keep details of incidents including those sustained during training. Independent specialist medical opinion before jockey deemed fit to race.
Rugby (*elite) None Five-minute 'Pitch-side Concussion Assessment' introduced by IRB, which can be requested by doctor or coach, covering mental ability and balance - player removed if shows one or more concussion symptoms. If suffering from concussion then cannot play for 23 days. Absence of recorded data. To return to play must receive medical clearance by a doctor or approved healthcare professional.
Football None FA guidelines state that no player should return to the pitch for 5 days after being subbed for a head injury. However, no penalty exists for breaking these guidelines, and evidence shows it has repeatedly been ignored. Absence of recorded data. To return to play must receive medical clearance by a doctor or approved healthcare professional.

How Boxing guidelines compare to other sports

Compare these rest periods to those recommended by the IRB and the difference is quite stark. An adult rugby player suffering concussion may return to play after just six days.

Even a child under the age of 15 can return to playing rugby after a concussion sooner than a boxer, with a permitted return to play as early as 23 days, albeit the graduated return can only commence following a two week rest period and is dependent upon the player being symptom free and off medication.

Concussion; whether caused by a blow to the head in boxing, a rugby or football tackle, or a horse riding accident carries the same risks to health and surely deserve the same level of attention irrespective of the sport? Perhaps there should be more done to encourage sporting organisations to fund and promote a universal approach to the recognition, diagnosis and treatment of concussion.

One man on a mission to achieve this is Chris Nowinski, a former WWE wrestler and American footballer. Chris was forced to retire in 2007 due to sustaining post concussion syndrome.

He has commenced a campaign called 'Head Games: The Global Concussion Crisis' and a documentary has been commissioned highlighting the risks, particularly to young people involved in sport.

The documentary premiered in London on 5 March 2014, the trailer can be viewed below and the full documentary is available to watch online here.

It is important that people are assessed after any head injury

We are all guilty of not making a fuss when something happens to us, especially when there is an apparent lack of physical damage such as a broken bone, cuts or bruises. But what tragically happened to sports players like Ben Robinson should serve as a warning to anyone takes a blow to their head to, stop and get it checked out from a medical professional as soon as possible.

In my experience of handling head injury compensation claims, early medical intervention and multi-disciplinary rehabilitation can make a huge difference to the level of recovery following any head trauma. It is also important to remember that family members will benefit greatly from support during what is often the most difficult time if the head injury leads to any traumatic brain damage.

...What do you think?

What do you think should happen when a head injury is suffered in sport? Should the injured be allowed to play on? Should there be an independent head injury assessment? Which sport has the best solution?

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