Concussion – What is to be done?

Photo: Nicolae Stoian

Professional soccer’s substitution habits and medical science’s best practices for treating concussions do not coexist with each other.

The brain

At a minimum, concussion specialists want 15 minutes to observe an individual whom they suspect of having been concussed. They want the time to check for the impact of what a layman would call “slow leaks,” “ooze,” or “swelling.” The brain case is utterly inflexible, has limited drainage capacity, and is so tight to its organ that any extra fluid or  tissue swelling causes pressure that can affect function.

Humans have known this for over 4,000 years. Ancient Egypt’s Pharaohs had skull surgeons whose major function was to drill a hole through the deity’s skull, in a last-ditch measure to save “the living god.”

Substitution habits

Professional soccer teams may make only three substitutions, and, once replaced, a player may not re-enter.

But playing down a man for 15 minutes to allow a potentially concussed individual to be treated and return — the minimums of medical safety — is not something a competitive team will do, voluntarily. Nor will the injured individual because the advantages granted the opposition would be too great.

So, sideline trainers and doctors send players back out prematurely, while watching them like hawks focused on prey. And players raised to believe that “getting your bell rung” is part of the game and a rite of passage to manhood – or womanhood – say, “I’m fine, coach. It just hurts. Put me back in.”

A medical professional who earlier in life has played the game is bear-trapped between the upper jaw of best health practices and the lower one of the competitive imperative. And of course no head coach wants to substitute for a starter unnecessarily.

A modest proposal

Since current custom is tragedy-in-waiting, here is a suggestion.

  • Increase the professional game day roster by one, to 19.
  • The 19th player is the “designated concussion substitute,” available ONLY as a temporary substitute, to allow minimum medical best practice to occur.
  • He, or she, may only enter the game when sideline medical personnel inform the referee that they are evaluating an injured player for a concussion, not for any other purpose, medical or otherwise.
  • As soon as the medical personnel are satisfied that the original player’s status is determined, either to return or be removed, the designated concussion substitute must leave the pitch, and, if necessary, be replaced by a different, permanent substitute under the regular rules of the game.
  • The designated concussion substitute may re-enter the game in case another medical concussion evaluation is needed.
Twice in one week

On June 5, 2016 Philadelphia Union Academy defender Mark McKenzie made his professional debut at left back against New York Red Bulls 2. Roughly 20 minutes into the game he was struck in the head by a defensive clearance at extremely close range. After about four minutes of evaluation by the trainer and a team doctor who had played the game as an undergrad in Canada, McKenzie returned to the field.

Quickly it became apparent that he was not “right,” and the doctor told him to take a knee. He was removed and helped to the dressing room, where evaluation continued past the end of a game that had a rain delay of at least an hour.

The young man went into concussion protocol, recovered, played quite successfully for Bethlehem again that season and in the spring of 2017, and replaced an injured Wake Forest co-captain for the ACC and NCAA tournament runs made by the Demon Deacons late last year.

Later in the same week McKenzie went down, at a Union home game Sebastien Le Toux took a blow to the head, came off the pitch, consulted the doctor for half a minute and returned. Seven minutes later he made one of his iconic lung-busting sprints-over-distance to contest a ball.

And after contact that did not involve any blow to the head, he slowly dropped to his knees with a vacant look on his face, and lay flat on the ground. He received treatment, and was removed from the game.

Le Toux had been concussed, and 30 seconds evaluating monsieur”Philly tough” had not found it.

That the USA missed the World Cup is an opportunity

Concussion threatens a human being’s life and personality. That is more fundamental than a game.

In this year of significant change in the landscape of soccer in North America, when its governing organizations do not have the distraction of participating in the world cup, they have a clear opportunity to focus energy on a major problem that threatens the game’s health.

Form a task force.  Convene conferences.  Thrash out alternatives and find the best one, or ones. As with VAR and goal-line technology, gain permissions and run tests, and modify the alternatives accordingly. Then implement them, or it.



  1. I love the idea of a “concussion substitute.” Problem is, it makes way too much sense to ever be implemented…
    My great fear is that it will take a death or massive crippling of a player on live TV for any league to make substantial changes. I really hope I’m wrong.

  2. Nick Fishman says:

    As someone with seven concussions (which may explain a lot), too often we err on the side of competition rather than caution.

    That needs to change. We need to ignore when a player says, “I’m fine.” Half the time we’re lying.

  3. I like your idea, but I agree with the above – change like this is just to unlikely. If as high profile a player as Taylor Twellman – who retired in his prime at 28 and has actively been promoting concussion awareness since – can’t really make any progress then it may be a lost cause. Though I think the substitution rule should be changed anyway (lots of suggestions for that).

  4. el Pachyderm says:

    What is to be done is the article’s question.
    here’s to the elephant addressing the problem and not discussing fixing symptoms acting as panacea….

    Let’s elevate the philosophy of play from moon ball and cross into the box to keeping the ball on the carpet and crossing into the box on the counter….. wait for it….with the ball on the ground.
    One such system of play, ManCity, has a decidedly crossing philosophy instituted by Guardiola in attacking the channels…thing is, the ball is crossed behind the defense on the ground. Granted this is an extreme example related to players and arguably the greatest coach ever.
    Here’s the important point to my post….I’d love to research the relevance of concussion in european countries or even South American as it relates to this game considering how intentional the play is—– more often than not…. to feet.
    My guess, hunch, educated opinion, hypothesis is….this is only an american problem.
    I know I know…. snob…right?

    • You can argue that, but it will never eradicate the issue. It’s a physical game. You still need to account for concussion awareness, even if (especially if) the number of occurrences declines.

    • Romelu Lukaku, Hugo Lloris, Christoph Kramer, Andros Townsend, Matthieu Flamini…

      Don’t ever change, Pachy. Don’t…ever…change.

      • el Pachyderm says:

        I will not.
        To be fair I did not write that head injury does not occur on other countries. What I would like to see is a study on the correlation of head injury to style of play.
        I think it worthwhile.

      • “My guess, hunch, educated opinion, hypothesis is….this is only an american problem.”

      • el Pachyderm says:


      • All good. We move forward together and hope for Union signings.

  5. Professional rugby has this one correct, in my opinion. A Head Injury Assessment (HIA) can be called for by the ref, a team’s trainer or the on-call physician at each match (that physician has access to replays of incidents to get an accurate picture of what happened). Once an HIA is signaled, the player leaves the field to be evaluated and any player on the bench can replace him/her. The duration of the HIA is a max of 10 minutes. If they determine the player can return within that time, they return. If not, their day is done. All of this is determined by the third party physician who answers to the league, not either team.
    The permanent substitution rule is more tricky, however, because in rugby, if you’re on the bench you can play, the only limit to the subs is the amount of players on the bench. Maybe it becomes a rule that if the physician rules that a player cannot continue, that team may replace the player, even if it represents a 4th or even 5th substitution (in the case of two head injuries in a game), but any player who fails an HIA must miss a minimum of two games, both for their safety and to keep teams from having tired players fake a concussion.

  6. I think soccer could use an injury substitute, period. Manchester City had to play with 10 men to wrap up their Crystal Palace matsch after both Jesus and DeBruyne were stretchered off the pitch. Not sure how to implement that in a way that would be free of teams exploiting it (faking an injury to get another player on). Perhaps any player removed for injury would be unable to play in the next match. Or, maybe just allow a 4th substitution. Maybe having a rule that any player who fails the concussion protocol must be replaced, regardless of subs left. That would make it specific enough to prevent exploitation.

    I don’t see how you can remove the risk of the game. Headers in the box only is interesting, but I don’t see how it’s feasible. Even the best tactics are going to produce balls in the air. (City’s Sergio Aguero scored the winner against Bristol City with a header.) Maybe Petr Cech helmets for everyone?

  7. Perhaps my old sport is a direction:

    In elite adult matches, which have been approved in advance by World Rugby (pursuant to Regulations 10.1.4 and 10.1.5) for use of the HIA (Head Injury Assessment) process, a player who requires an HIA:

    Leaves the field of play; and

    Is temporarily replaced (even if all the replacements have been used).

    If the player is not available to return to the field of play after 10 minutes (actual time) of leaving the playing area, the replacement becomes permanent.

  8. The rugby rules are definitely interesting.
    A minimum time off the field is a must, and as someone suggested earlier get a league (not team) medical official who would approve either the player returning or an injury sub

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