Lagging behind on concussion-risk awareness

"Who scored the last goal?" What may sound like a funny question to ask when the score is still 0-0 is worth asking when trying to ascertain whether a player has sustained a concussion and needs to be subbed off.

The German national football team's physio asked this question, which is suggested as part of the SCAT 3 test, of Christoph Kramer (pictured above) after he took a strong blow to the head in the 17th minute of the World Cup final in Rio de Janeiro in 2014. Kramer, who played on until being subbed off in the 31st minute, later couldn't remember anything about the last 14 minutes that he was on the pitch.

"I can't even remember that I played on," he said.

The incident, watched by millions of fans on live television, did much to raise awareness in Germany of the risk of concussion in football.

NFL settlement

In the United States, though, concussions have been a major issue for years now. In mid-December, the US Supreme Court  approved a $1 billion settlement between the National Football League and around 20,000 of its former players who have been diagnosed with brain injuries linked to repeated concussions. This was seen as a major breakthrough for the victims of concussions, after the NFL had spent years disputing the ling between concussions and illnesses such as chronic traumatic encephalopathy (CTE). CTE, which occurs as a result of concussions not being allowed to heal completely before a player returns to action and the effect is cumulative over a number of years. This can lead to irreparable damage and the symptoms range from headaches to blurred vision, to personality disorders, depression and dementia. The first to identify the problem was neuropathologist Benett Omalu and a Hollywood film has since been made about his discovery.

'High probability' of concussions in soccer

"The probability of suffering a head injury in soccer is quite high," said Dr Werner Krutsch, a trauma surgeon and specialist in football injuries ad the University Clinic Regensburg.

"These injuries need to be correctly diagnosed and treated. Unfortunately, in sports, trivialization remains a problem," he said.

From a medical point of view, Kramer should have been immediately subbed off in the World Cup final and Dieter Hoeness, who famously played on with a turban in the 1982 German Cup final, should not have been allowed to. However, just like in American football, in soccer, being a hard man is a quality appreciated among both players and fans, and so far, little has changed in this regard.

Dangerous even if it is difficult to recognize

Minor concussions, in which the victim doesn't lose consciousness and experiences no clearly recognizable symptoms, are a particular problem.

"We don't yet have any tools to help us diagnose such small brain traumas," Krutsch said.

This applies to professional athletes but even more so in the amateur ranks, so raising awareness is highly important. Former German national ice hockey team captain Stefan Ustorf, who still suffers from symptoms linked to head injuries suffered during his playing career, is working to do so through his own club, as is the Hannelore Kohl Foundation, whose app, meant to help athletes self-diagnose concussions, is in the testing phase.

Technical support is already established in North American professional football and hockey leagues. Some teams put their players through something known as Immediate Post-Concussion Assessment and Cognitive Testing (IMPACT), prior to the start of the season. If a team's medical staff suspect that something may be amiss with a player during the season, the test came be repeated and they can compare the results. The player in question is only meant to return to action when he achieves the values of the pre-season assessment.

In light of the high number of CTE cases, the NFL has tightened up its regulations, ruling that should any team fail to adhere to the protocols on brain injuries, the league reserved the right to impose stiff penalties.

German soccer lagging behind

However, there is nothing like this in German football, with both the German football league (DFL), which operates the Bundesliga, and the German football association (DFB) saying they are still working to come up with common standards.

One improvement, though, is the fact that since 2006 deliberately elbowing an opponent in the head is a sending-off offences. In 2014, UEFA introduced the "three-minute break," which is meant to allow the team doctor time to make a diagnosis in the case of a knock to the head.

No long-term studies in Germany

And what about the long-term effects on soccer players? There have in fact been isolated reports about former professional players who have suffered from symptoms related to concussions or who have been posthumously diagnosed with CTE. This points to a link between soccer and concussions, but this is a long way from scientific proof.

"There have been no long-term studies about this subject in soccer, because there has been not demand for it," Dr. Kritsch said. "When you look at the force of an elbow to the head in ice hockey, which is part of the sport, there is simply no comparison with soccer."

Other experts aren't so sure about that, and over the next few years, the Bonn-based Federal Institute for Sports Sciences is aiming to launch a number of research projects into the matter. In its very title, a report that it released last autumn described concussions in soccer as an "underrated risk."