During the 2018 soccer World Cup, the Federation Internationale de Football Association's (FIFA) own concussion assessment protocols were not followed in more than 60 percent of head collisions where players showed two or more signs of concussion, according to a recent study published in JAMA Neurology. 

To evaluate concussion assessment and management during the 2018 World Cup, Ajay Premkumar, MD, MPH, of Hospital for Special Surgery in New York, NY, and John Xerogeanes, MD, chief of sports medicine at Emory University in Atlanta, Ga., along with other colleagues from Emory, analyzed video footage of all 64 matches of the tournament, identifying any possible concussion events. They noted an average of 1.8 head collisions per game, and that the majority of players were not evaluated by healthcare personnel, even after a head collision event and demonstrating two or more signs of concussion. When evaluation did occur, the average length of on-field assessment was less than one minute and not standardized.  

FIFA, the organizing body of the World Cup, has a history of facing criticism due to poor concussion assessment and management in prior international tournaments. Prior to the 2018 World Cup, FIFA responded by updating its concussion policies; however, it appears that FIFA’s concussion policy changes did not lead to enhanced concussion management, rendering these policy changes ineffective. 

Compared to other regulatory sporting bodies, such as the NCAA and NFL, which have adopted and implemented safety measures such that any player exhibiting signs of concussion are identified and go through a standardized concussion protocol prior to return to play, it appears that in international soccer, there remains decreased identification of potential concussions as well as a lack of standardized concussion management for those players who are identified.

“While the incidence of feigning injury for strategic advantage during a game may provide a challenge in appropriately identifying players at risk, healthcare personnel cannot reliably distinguish a concussion from gamesmanship without evaluating the player,” explains Xerogeanes. “We recommend that all players be evaluated when exhibiting any signs of concussion.”

“Concussion assessment protocols and their implementation by large sporting governing bodies may have widespread effects on the officiating, coaching and play of athletes of all levels around the world; however, we suggest utilization of standardized assessment tools as well as exploration of rules around player substitutions during injury evaluation,” says Premkumar. “These possible avenues will help improve concussion assessment and management in international soccer.”