During four separate World Cup concussion incidents, FIFA’s concussion protocols were brazenly thrown aside by team medical staff, with no ramifications from FIFA – an organization that is supposed to have the player’s best interests and safety at heart.
It’s crystal clear that the short-term needs of the team continue to outweigh the short and long-term safety of the players and FIFA’s feeble response without holding medical staffs accountable continues to reinforce that mindset. It’s completely irresponsible and unacceptable.
To illustrate how poorly World Cup concussion has been handled, lets start by reviewing each one:
I. World Cup Concussion Incidents
A. Morocco’s Nordin Amrabat
The first World Cup concussion was the most blatant. Morocco’s winger Nordin Amrabat was involved in a collision and after hitting the ground exhibited a stiffened posture known as the “fencing response” (for more on that, I wrote about it here). The fencing response is highly indicative of concussion.
Here’s the incident:
The Moroccan medical staff physically picked him, gave him some slaps on the face to make sure he was conscious, and a Moroccan player squirted water on him – all the while Amrabat was stumbling around and hunched over:
You have to evaluate him for a concussion right? Nope. He then spent the night in the hospital and is on record saying he doesn’t remember the match or the hours between the match and getting to the hospital.
To top it all off, the Moroccan medical staff again broke protocol when they allowed Amrabat to play 5 days later even though FIFA concussion protocol clearly states that he should’ve been out at least 6 days before returning to game action.
B. Iceland’s Ragnar Sigurdsson
Iceland centerback Ragnard Sigurdsson was kneed in the back of the head in the 49th minute of Iceland’s 2-0 loss to Nigeria, immediately clutching the back of his head while writhing around on the ground.
He stood up with the help of the medical staff, had his head bandaged, went off the field for a minute, and then returned. No concussion evaluation was performed and he was subbed out 16 minutes later.
Here’s video of the incidence and the exact timeline:
48:24 #Iceland's Ragnar Sigurdsson hit, stays down
49:40 Medics arrive
53:41 Returns w/head bandage & no concussion eval
65:00 Subbed out
— Chris Nowinski, Ph.D. (@ChrisNowinski1) June 22, 2018
Who needs medical diagnostics or expertise when you have Icelandic bandages. I know Iceland is a beautiful, magical place but this is taking it to the next level.
C. Peru’s Renato Tapia
Another early World Cup concussion incident took place in Group C match play when Peru center back Renato Tapia was knocked to the ground after colliding with Denmark’s Simon Kjaer. Here’s the incident at hand:
Peru's Renato Tapia is not moving when the referee arrives after a severe body-to-head impact, yet is not evaluated, & returns. When he finally stands up, FS1 commentator says, "It looks like he's fine." Watch the video: pic.twitter.com/ix8fX64ISQ
— Chris Nowinski, Ph.D. (@ChrisNowinski1) June 16, 2018
Take a wild guess at what happened next. fI you guessed “a brief cursory check before being doused in water” then you are correct.
FIFA #concussion protocol in spotlight late in today's Denmark-Peru World Cup match. Peru's Renato Tapia left the field after taking heavy hit to the head. As a trainer doused Tapia's head with water, FS1 announcer said, "Cold water is not enough, my friend." pic.twitter.com/XN2TCdt3gG
— Dr. Javier Cardenas (@theconcussiondr) June 16, 2018
Water cures all evidently. It’s effects must have worn off 13 minutes later when he was subbed off.
He missed the next match against France and here’s the kicker: Tapia doesn’t even remember the match. Clearly he needs some of the magical Icelandic bandages.
And that brings us to the last World Cup concussion, which occurred during the semifinals…
D. France’s Blaise Matuidi
Blaise Matuidi’s face collided with Eden Hazard’s arm and elbow during France’s semifinals against Belgium. Here’s the collision:
— Henry Bushnell (@HenryBushnell) July 10, 2018
He was tended to by his teammates, taken to the sideines up by the medical staff, and allowed back into the game after fifteen seconds.
Yes you read that right. FIFTEEN seconds. Either that sideline is part of a time altering vortex or something is very wrong here.
You can probably guess what happened next. He was subbed off 2 minutes later when he collapsed to the ground:
France's Blaise Matuidi was involved in a collision & taken to the sideline. Docs evaluated him for a whole 2 minutes before clearing him to return.
He lasted less than 2 minutes before collapsing.
I'm very tired of this. pic.twitter.com/Bw8sn8etTs
— Chris Nowinski, Ph.D. (@ChrisNowinski1) July 10, 2018
No big deal, he’s probably just tired and likes the feel of the grass on his skin, gently enjoying the warm glow of the sky against the ever-changing clouds.
Matuidi’s face has now become the poster boy for mishandled World Cup concussion (something Germany’s Christoph Kramer can take solace in at least, more on him below):
Blaise Matuidi does not look OK. pic.twitter.com/19OoD8WY6y
— Jeff Eisenband (@JeffEisenband) July 10, 2018
I wish I was making this up. I almost expect FIFA to pull back the curtain and say “We got you! Wave at all the hidden cameras! You didn’t actually think we could be THIS oblivious right?”…it’s that ridiculous.
Leaving these players in without proper assessment of head injury opens them up to so much risk and here’s why:
II. The Potential Repercussions
Leaving in a player in after a concussion is dangerous on multiple fronts:
A. Concussion is a Traumatic Brain Injury
A concussion is considered a mild traumatic brain injury (MTBI) so I’ll use the terms interchangeably from here on.
If you or someone you knew potentially had a traumatic brain injury of any sort – would you waive it off, throw some water on them, and let them proceed with their day, let alone continue to play sports?
No of course not. That’s an instant “you’re getting that checked out right now”. (and you might be surprised to learn that soccer is second only to football in terms of concussions per year in the United States)
B. Delayed Symptoms
Symptoms of concussion/TBI may not show up immediately and can take hours to manifest. That’s why a detailed neurological examination (which on average takes 10 minutes) and erring toward caution are tantamount for player safety.
C. Longer Recovery Times
Research clearly shows that a player with a concussion/MTBI who continues to play has a significantly longer recovery time than a player who is removed from the game.
D. Second Impact Syndrome
There’s a phenomenon known as “second impact syndrome” in which two concussions/MTBIs in quick succession can lead to very severe and sometimes life-threatening symptoms.
E. Fair Play
Putting safety aside for a quick second and focusing on the fairness of competition itself – it’s not fair to the player, teammates, opponents, or fans to allow a player with concussion/MTBI to still be on the field. A concussion/MTBI can affect so many functions that are integral to sports and can lead to major mistakes that affect the outcome of a game.
A high-profile recent example of that is Liverpool keeper Loris Karius who suffered a concussion/MTBI during Liverpool’s Champions League Finals match. He took a elbow to the head from Sergio Ramos, wasn’t checked, and then made two critical mistakes leading to goals (both of which lined up with his post-match concussion/MTBI testing and symptoms).
He was unfairly lambasted by the worldwide media and Liverpool fans (none of which would help his mental state during recovery) but lets also think about about the Liverpool players, coaching staff, and fans who had worked so hard all year to get to that moment and were right in the game. The medical staff has a responsibility to the player and the competitive spirit of the game to do their job, do it extremely well, and be a responsible decision-maker.
For a detailed look at the entire Loris Karius situation, click here.
Knowing these risks and seeing these World Cup Concussion incidents, you’d imagine FIFA would respond swiftly and harshly. This is player health and their brains after all…
III. FIFA’s Response
So how has FIFA responded to these World Cup concussion incidents and transgressions…did they drop the hammer and send a resounding message that this cannot be accepted, something like this:
Nope, rather you had FIFA doing this:
Looking the other way with barely a peep. Their response to Morocco’s medical staff is case in point.
Nordin Amrabat had an obvious indicator of concussion/TBI (the fencing response) yet was never evaluated by Moroccan medical staff. As the cherry on top, the medical staff broke protocol again by allowing him to play 1 day earlier than the protocol states (he played 5 days after his concussion/TBI, should have been 6 days).
Football has its head up its ass.
Nordin Amrabat is playing for Morocco despite being concussed at the weekend, spending a night in hospital, and the Moroccan FA saying he’d be out for at least a week.
— Andy McGeady (@andymcgeady) June 20, 2018
FIFA responded with…wait for it, wait for iiiiiitttttttt…..writing a letter to the Moroccan team doctor to remind him of the guidelines. Way to tell em and really reinforce the importance of the protocol.
Here’s how Morocco responded to that letter, starting with the involved player, Nordin Amrabat:
“A week is the official time you should recover for to make sure that you are safe but I decided to make it shorter. I Googled the consequences that concussion can have on someone and I thought I can do it, I can play.”
I don’t understand why FIFA got involved. They sent a letter to our doctor regarding the procedure after a concussion and the treatment he gave me on the pitch. I am my own doctor and hopefully nothing will happen to me in the long term.
Even though he can’t remember anything from the first match:
“I can’t remember anything from it (the first concussion and match). I can’t even remember the beginning of the game before the incident. From the first minute of the match until I woke up in the hospital five or six hours later“
Secondly, there was Morocco’s head coach Harve Renard actually praising Amrabat for his decision:
“He is a warrior. He wanted to play.”
And when Renard was asked why Amrabat took off his head protector 13 minutes into the match:
“Because his spirit was amazing”
Renard’s message reinforces the complete disregard for the protocol. Maybe FIFA should send a carrier pigeon message next time.
Adding more fuel to this trashcan fire is that FIFA actually implemented new rules after the 2014 World Cup and recently in February 2018 to improve player safety and assessment of World Cup concussion.
IV. FIFA’s Addendum on Concussion/TBI Rules
- Implementing a new education program for team doctors, coaches, referees, officials and players
- Referee will have the ability to stop the match
- 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 authorization
- Additionally, in February 2018, FIFA implemented in-game video review of concussion/TBI incidents where a member of the medical staff could assist the primary Doctor in diagnosis via video review
Those rule changes were based on multiple World Cup concussion incidents and medical teams not assessing for head injury. In fact, a study of 2014 World Cup concussion examined video footage of all 64 matches and found that medical professionals examined players for concussion in only 12 instances of 72 separate events that could be indicative of head injury or concussion/TBI.
That’s 15% of all incidents. FIFTEEN percent.
One incident in particular – Christoph Kramer’s concussion in the Argentina-Germany final – highlighted the 2014 World Cup concussion problem.
In the 17th minute, Christoph’s head made hard contact with the shoulder of Argentinean defender Ezequial Garay and he instantly crumpled to the ground (go to the :10 sec mark):
He was never taken out of the game and evaluated for concussion/TBI. Moments later had this exchange with an official:
Kramer (to referee Nicola Rizzoli): “Ref, is this the final?”
Rizzoli thinks he’s joking and makes him repeat the question: “I need to know if this is really the final”
Kramer: “Thanks, it was important to know that”
You can’t make that up.
13 minutes later, he was finally pulled out of the game after slumping down to the ground and had to be physically helped off the field by two medical personnel:
Here’s what he said in a post-match interview:
“I can’t really remember much of the game. I don’t know anything at all about the first half. I thought later that I left the game immediately after the tackle. I have no idea how I got to the changing rooms. I don’t know anything else. In my head, the game starts from the second half.”
That embarrassing sequence on the biggest stage of soccer was the major impetus for rule changes following the 2014 World Cup. However, it’s clear that teams continue to not follow the protocols and FIFA’s impotence just reinforces that disregard.
So what can FIFA do going forward?
A. Enforcing the current rules
The first step for FIFA is pretty simple: stringently enforce the current rules. They took some good steps after the 2014 World Cup with the new rules but without enforcing them, you might as well not have any.
These scathing quotes from Players Football Association (PFA) chairman Ben Purkiss sum it up nicely:
“You can have the best drafted, shiniest rule book on the table but if you don’t apply it, what’s the point? There’s no point whatsoever. You can say you’ve looked into it and we’ve done this, that and the other. It’s about how things are applied in practice.
“Whenever you ask players how they are, their instant reaction is ‘I’m fine’ because they don’t want to be accused of not going through a brick wall for the cause. That’s why it’s crucial the protocols are in place and the decision has to be taken out of the hands of both players and managers.”
There have to be consistent and serious consequences or we’ll continue to see the same type of disregard for World Cup concussion /MTBI safety. After all, in the words of George RR Martin “words are wind”.
You ever going to finish that next book George? Good grief.
Additionally, FIFA needs to work towards improving the current rules as well because there are unrealistic parameters and gaping holes. These include…
B. Increasing the time limit for evaluation
Right now the medical staff is allotted 3 minutes to examine a player for concussion. However, a reliable and valid concussion evaluation can take 10 minutes, on average.
As it stands, even if the medical staff chooses to assess a player, the 3 minute rule limits accuracy of evaluations. Therefore, the time limit needs to be increased to 10 minutes to allow for proper assessment.
To account for this longer period of time off the pitch and maintain competitive balance, new substitution rules need to be implemented…
C. Substitution rules
1 – Temporary sub
When a player is suspected of possible concussion/TBI and taken off the pitch for 10 minutes, a replacement player would be allowed on in the interim
2 – Extra sub
If that player taken off is confirmed to have concussion/TBI then the interim sub becomes a permanent sub, and an extra sub is allotted to make up for that change. Currently, FIFA has only allowed for an extra 4th sub during extra time games.
Premier League doctors have vehemently been asking for increasing the time limit to 10 minutes and temporary + extra sub rule.
To bolster medical decision making even further, FIFA needs to mandate an…
D. Independent doctor making decisions
In an ideal world, the team medical staff would make decisions based on player safety and player safety alone, with no weight given to the team circumstances or gravity of the match. They would err on the side of caution with all players.
However, that’s not the reality, as we’ve seen far too many times in this World Cup and beyond. Team medical staff know how much rests on the outcomes of these games and further know they will could face the wraith of the coach, team, fans, federation, and even the player themselves if they mistakenly pull a player out and things don’t go well.
These factors bias medical decision making, especially when you don’t have enough time to complete an accurate diagnostic in the first place. Medical staff are still human after all.
For these reasons, an independent doctor who isn’t associated with the team or team outcomes needs to be making the final call.
So that’s most of the major changes FIFA needs to make but there’s one important piece left…
E. Expanding Video Review
As I briefly touched on earlier, FIFA recently allowed for a second member of the medical staff to review a replay of the possible concussion/TBI incident and help the on-pitch doctor with diagnosis.
However, that scope for video review is far too limited. It’s only used if an evaluation has already been triggered. The video review can be expanded for medical staff on the sidelines or in the stands to review incidents with video playback, such as with tablets, that they initially missed.
The English Premier league has allowed this since 2016 and UEFA is highly considering it after the Loris Karius debacle. Being part of a professional medical staff isn’t an easy job, lets give as many tools as possible to help.
The overall point of all these changes is, first and foremost, to increase player safety. Secondly, these changes would decrease the pressure on medical staffs to rush to judgement regarding a concussion/MTBI diagnosis and decrease the pressure on players, especially goal keepers, to stay in the game after head injury.
Dr. Willie Stewart, a British neurosurgeon who has been a champion for improving head injury assessment in soccer and rugby, summed it all up when he told BBC Sport:
“Football doesn’t allow an interchange for a player to be assessed to see if he has a brain injury; doesn’t allow significant time for the medics to assess the player; doesn’t have a video review of events to be able to say if there was a glancing blow on my goalkeeper’s head which I didn’t notice.
“It’s unacceptable in 2018 that it should be this way.”
PREACH BROTHA, PREACH
So those are the changes but Will FIFA actually do anything?
When it comes to independent doctors and expanding video review – only time will if this string of World Cup concussion incidents and disregard for protocol forces FIFA’s hand.
However, the handling of Nordin Amrabat’s concussion/TBI, specifically being cleared to play a day earlier than the FIFA protocol, may have struck a nerve with the FIFA medical chief Michael D’Hooghe. He hinted at possible penalties and sanctions for teams now following FIFA concussion/TBI protocols:
“We thought that with these guidelines we had enough power, but it seems now that this is not the case.’ Perhaps we need to go one step further and impose sanctions if the guidelines are not followed”
It’s sad to say but FIFA even considering a change is a win.
Unfortunately, FIFA is not considering changing time limits or new substitution rules, as told again by FIFA’s medical chief Michel D’Hooghe to the Telegraph:
“I am not in favour of temporary substitutions, for many reasons”
Further, he went on to imply that teams may abuse and exploit the rules for tactical gain, and then poo poo’d the idea of longer evaluations with hyperbole while also admitting the current time limit doesn’t allow for a complete evaluation:
“Of course, this is not enough for a complete neurological examination, but we cannot ask the referee to stop the game for 35 minutes”
Cmon. I understand the reservations but there was a time when goal-line technology and VAR were also looked upon with doubt. We have to change for the better when player safety and health are on the line but unfortunately FIFA moves at a snail’s pace of progress.
My only hope is that progressive leagues like the English Premier League have enough influence to pull larger organizations like UEFA into the future which then puts the pressure on FIFA to do the same. Hopefully this happens before a player gets critically hurt which leads to FIFA scrambling around reactively and giving press conferences on how much they care about player safety as exhibited by new rules to make sure it never happens again.
VI. All in All
These World Cup concussion /MTBI incidents and lack of following protocol are flat-out unacceptable. I’m literally sitting here shaking my head as I type this.
Then you add in FIFA’s lack of response or ramifications, and I’m sitting here about to knock my Kombucha off the table.
It’s frankly embarrassing that the highest governing body of soccer continues to place (and reinforce) the short-term needs of a team over that of player safety while undermining the competitive fairness of the sport. It has to change and I hope this piece can help bring some awareness to the issue.
Thanks for reading and until next time.
If you want the latest articles delivered straight to you, subscribe to the email list on the sidebar.
If you’re interested in details on injury prevention and rehab, sports performance, stress management or want to set-up a free consult & injury screening, check out my clinic 3CB Performance.
If you’re interested in the latest NBA and NFL updates, check out ClutchPoints.