UK brain injury expert condemns football’s concussion protocols as a ‘shambles’ compared to rugby

Football’s concussion protocols are a shambles, according to one of the UK’s foremost brain injury experts.
David Luiz of Arsenal receives treatment from physio Jordan Reece for a head injury during the Premier League match last November. Photo by David Price/Arsenal FC via Getty Images.David Luiz of Arsenal receives treatment from physio Jordan Reece for a head injury during the Premier League match last November. Photo by David Price/Arsenal FC via Getty Images.
David Luiz of Arsenal receives treatment from physio Jordan Reece for a head injury during the Premier League match last November. Photo by David Price/Arsenal FC via Getty Images.

Professor Willie Stewart told MPs on the Digital, Culture, Media and Sport (DCMS) committee that he could not understand why the sport had chosen not to follow rugby’s path in introducing temporary substitutions and therefore allowing a longer period of time for a potential concussion to be assessed.

He also expressed concern that there was a lack of research into head impacts in women’s sports, given the increased risk to women of concussion, saying: ‘I don’t think we’re giving it nearly enough attention.’

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Stewart led the FIELD study at the University of Glasgow which in 2019 established that professional footballers were three and a half times more likely to die of neurodegenerative disease than age-matched members of the general population.

He believes on the balance of probabilities that head impacts across a range of sports are responsible for the increased risk of diseases such as dementia among elite athletes, and could not understand football’s approach to managing concussion.

‘Football has a habit, whenever it is forced to develop, of going out on their own and trying to develop something unique to everybody else as if the problem never occurred before,’ he said.

‘What football has introduced is a shambles in 2021.’

Football’s lawmaking body the International Football Association Board (IFAB) approved protocols last December to trial the use of permanent concussion substitutes, with the initial on-field assessment period remaining at three minutes before next steps – further examination or a substitution – are taken.

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Asked whether the temporary substitute model was preferable, Stewart said: ‘Unquestionably. Rugby has made great developments in understanding how you can assess and identify players with brain injury on the field, and that should be the model and the benchmark that (other) sports start from.

‘They shouldn’t be starting with a blank page and drawing up a protocol, they should just be saying ‘how do we make that happen in football?’.

The Football Association is participating in a trial of one of the IFAB’s protocols, and feels the permanent substitute model chimes with its co approach to concussion. It feels there is a greater risk of a secondary concussion if, after a longer assessment period, a player is allowed to return to the action.

The IFAB has been asked for comment.

The parliamentary inquiry comes at a time when a legal action is under way in rugby union involving a group of former players suffering with brain disease, while similar actions are being prepared in rugby league and football.

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It also comes less than six months after the death of England’s 1966 World Cup-winning midfielder Nobby Stiles, who Stewart discovered postmortem was suffering from chronic traumatic encephalopathy (CTE), a brain disease only seen in those who have suffered repetitive head trauma.

Stiles’ England and Manchester United team-mate, Sir Bobby Charlton, has also been confirmed to be living with dementia.

One area of particular concern to Stewart is the lack of research on the impact of head injuries among women.

‘I think what does concern me is that while the rules for men’s football and women’s football are exactly the same, the risk of concussion in women’s football is about twice that in men’s football,’ he said.

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‘So the risk of injury is doubled. That repeats itself through rugby and various other sports, so we would definitely have a concern about what the long-term consequences of that might be. If they are twice as high risk of developing a symptomatic brain injury, what does that mean many years down the line? We really need to get ahead with that research.

‘In the simplest way, if a school or a club have a physio or a doctor available on a Saturday afternoon and there are a couple of matches on, they should be standing at the sidelines of the ladies game because that’s where the injury, in terms of a brain injury, is going to happen.

‘But inevitably what they’re doing is standing at the sidelines of the men’s game. I don’t think we’re giving it nearly enough attention.’

Steps have been taken to mitigate any potential risks from repetitive heading in girls’ and boys’ football, with the national associations of England, Northern Ireland and Scotland advising coaches not to practise heading in training with children aged 11 and under.

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A working group is also looking at the possibility of introducing limits on heading in training at senior levels of the game.

Stewart, along with Professor Craig Ritchie from the Centre of Clinical Brain Sciences at the University of Edinburgh, said they hoped that sports would apply the “precautionary principle”, particularly in relation to children’s participation, and remove any unnecessary risk.

Peter McCabe, the chief executive of brain injury charity Headway, said he and his organisation felt ‘patronised’ by the football authorities, and had engaged more closely with rugby and hockey.

‘It’s been a bit one-sided to be honest,’ he said.

‘We’ve made efforts going back as far as 2013 to have dialogue and we feel like we have been a bit patronised, to be frank.’