Day 23 of the 2010 FIFA World Cup and Ghana is playing Uruguay in the quarter-finals at Johannesburg’s Soccer City Stadium. Forty minutes in, the game is tight and both teams have yet to score a goal. Uruguayan player Jorge Fucile is playing as if his life depends on it. Suddenly, he attempts to intercept the ball by heading it. As Fucile leaps up, not only does his head miss the ball, but he also crashes into Ghanaian player Samuel Inkoom. The collision causes Fucile to tumble backward and his shoulder and head bear the brunt of the impact when he hits the ground. Fucile lies face down in the field and the officials run over to assess his condition.

In soccer, concussions typically occur from player-to-player contact, heading the ball, and contact with the ground or goalposts. A 1999 article in the Journal of the American Medical Association (JAMA) found that 59% of concussions occur while heading the ball and 30.5% occur during “non-heading” player-to-player contact. However, FIFA Medical Assessment and Research Centre’s study of 398 soccer matches found that all 14 reported concussions were caused by “non-heading” player-to-player contact.

Concussion rates vary widely because of inconsistent definitions or diagnosis of concussion and underreporting by players. While soccer players are commonly believed to be at lower risk for concussion than athletes in other contact sports, some studies refute this idea. The NCAA reported that collegiate soccer players have the highest rate of concussions in organized contact sports that do not involve helmet protection. Studies have revealed that 25% to 40% of soccer athletes have suffered a concussion by the time their high school career ends.

Current studies contradict each other on the likelihood of a concussion occurring when the head comes in contact with the ball. Some studies have shown no adverse effects in neuropsychological test performance between “headers” and “non-headers” after training and matches. Nevertheless, in a 2004 discussion paper, the Canadian Academy of Sport Medicine advocated teaching players proper heading techniques that may decrease the amount of force transmitted to the brain.

When the referee reaches Fucile, he has not lost consciousness and several minutes later he is able to stand and converse with officials. He is deemed well enough to play the rest of the match and Uruguay wins in the final shootout.

The next day, the team’s medical staff announces that Fucile is still under observation as a result of the fall. "He is okay. He suffered concussion after bumping his head, but he did not lose consciousness. But we have to take care of his state of health," said team doctor Alberto Pan. One week later, Fucile plays in a match between Uruguay and Germany. The game ends without any major incident for Fucile, but Germany manages to beat Uruguay 3-2.

While past studies have reported that a history of concussion poses significant risks for future concussion, the mechanism that controls this increased risk has yet to be identified. A 2003 JAMA study suggested that the mechanism of impaired glucose metabolism from a single concussion is a likely factor.

A 2001 study in the Clinical Journal of Sport Medicine suggests that there is enough data to anticipate finding cumulative neurological consequences in soccer not unlike the increased neuropathy found in the brains of boxers who had sustained chronic head injuries.

Computerized neuropsychological testing is playing an increasing role in the assessment process. One notable provider of this testing is the Australian company CogState. Its “Sport” service tests the cognitive performance by taking baseline measurements of the athlete pre-season to enable detection of any cognitive changes should a concussion occur. CogState’s customers include FIFA and the UK Rugby Football League. During FIFA’s 2007 survey of its 207 member associations, it counted 265 million participants. To make testing feasible with such a large number of players, CogState developed test batteries that can be administered reliably and repeatedly by non-experts.

Additional research is being done in prevention, particularly around the efficacy of soccer headgear. In 2008 McGill Sport and Medicine Clinic looked at the effect of protective headgear in adolescent female soccer players. Among the population studied during one season, 27% who wore headgear and 53% who did not wear headgear suffered concussions. Of the concussed athletes who wore headgear, 50% suffered more than one concussion, while 70% of the concussed athletes who did not wear headgear experienced additional concussions. Currently, there is no national standard for soccer headgear in Canada, but studies like this could lead to more protective headgear use among future players.

Diagnosis and assessment of concussions in athletes has made great progress during the last fifteen years.

  • Concussions with no loss of consciousness are seldom being dismissed as temporary injuries
  • Sport guidelines are being developed that prevent secondary head injuries and complications
  • Medical practitioners in all fields are closer to agreeing on a multidisciplinary approach to evaluation and assessment
  • More objective testing methods such as computerized neuropsychological testing are being adopted
  • Research is ongoing to better understand the pathology and long-term effects of concussion

There is reason to be optimistic about diagnosis, assessment and treatment of concussion in the athletes of tomorrow.