Concussions in sport

Concussions, a type of traumatic brain injury, are a frequent concern for those playing sports, from children and teenagers to professional athletes. Repeated concussions are a known cause of various neurological disorders, most notably chronic traumatic encephalopathy (CTE), which in professional athletes has led to premature retirement,[1] erratic behavior and even suicide. Over 1.6 million Americans have sustained concussion-related injuries.[2] Because concussions cannot be seen on X-rays or CT scans, attempts to prevent concussions have been difficult.[3]

The dangers of repeated concussions have long been known for boxers and wrestlers; a form of CTE common in these two sports, dementia pugilistica (DP), was first described in 1928. An awareness of the risks of concussions in other sports began to grow in the 1990s, and especially in the mid-2000s, in both the medical and the professional sports communities, as a result of studies of the brains of prematurely deceased American football players, who showed extremely high incidences of CTE (see concussions in American football).

As of 2012, the four major professional sports leagues in the United States and Canada have concussion policies.[4] Sports-related concussions are generally analyzed by athletic training or medical staff on the sidelines using an evaluation tool for cognitive function known as the Sport Concussion Assessment Tool (SCAT), a symptom severity checklist, and a balance test.[5]


Concussion symptoms can last for an undetermined amount of time depending on the player and the severity of the concussion. A concussion will affect the way a person's brain works.[6]

There is the potential of post-concussion syndrome, post-concussion syndrome is defined as a set of symptoms that may continue after a concussion is sustained.[7] Post-concussion symptoms can be classified into physical, cognitive, emotional, and sleep symptoms.[7] Physical symptoms include a headache, nausea, and vomiting.[7] Athletes may experience cognitive symptoms that include speaking slowly, difficulty remembering and concentrating.[7] Emotional and sleep symptoms include irritability, sadness, drowsiness, and trouble falling asleep.[7]

Along with the classification of post-concussion symptoms, the symptoms can also be described as immediate and delayed.[8] The immediate symptoms are experienced immediately after a concussion such as: memory loss, disorientation, and poor balance.[8] Delayed symptoms are experienced in the later stages and include sleeping disorders and behavioral changes. Both immediate and delayed symptoms can continue for long periods of time and have a negative impact on recovery.[8] According to research, 20-25% of individuals who have sustained a concussion experienced chronic, delayed symptoms.[8]

Playing through concussion makes people more vulnerable to getting hit again, and that is why most sports have test that trainers will perform to prevent getting hit a second time. A second blow can cause a rare condition known as second-impact syndrome, which can result in severe injury or death.[9] Second-impact syndrome is when an athlete suffers a second head injury before the brain has adequate time to heal in between concussions.[10]

Repeated concussions have been linked to a variety of neurological disorders among athletes, including CTE, Alzheimer's Disease, Parkinsonism and Amyotrophic lateral sclerosis (ALS).[11][12]


It is estimated that as many as 1.6-3.8 million concussions occur in the US per year in competitive sports and recreational activities; this is a rough estimate, since as many as 50% of concussions go unreported.[13] Concussions occur in all sports with the highest incidence in American football, hockey, rugby, soccer, and basketball.[5] In addition to concussions caused by a single severe impact, multiple minor impacts may also cause brain injury.[14]

Injury rate per exposure based on sport in collegiate athletes from 1998 to 2004[15]
Sport Injury rate per 1,000 athletic exposures
Women's ice hockey 0.91
Men's spring football (American) 0.54
Men's ice hockey 0.41
Women's soccer 0.41
Men's football (American) 0.37
Men's soccer 0.28
Men's wrestling 0.25
Men's lacrosse 0.25
Women's lacrosse 0.25
Women's basketball 0.22
Women's field hockey 0.18
Men's basketball 0.16
Women's gymnastics 0.16
Women's softball 0.14
Women's volleyball 0.09
Men's baseball 0.07
All sports 0.28


Major League Baseball

Major League Baseball's policy was first started in 2007, and injured players are examined by a team athletic trainer on the field.[16] On March 29, 2011, MLB and the Major League Baseball Players Association announced that they have created various protocols for the league's concussion policy. The new policy includes four primary components:[17]

National Basketball Association

The National Basketball Association does not have a policy, and team procedures after concussions vary by team.[16] The NBA has a meeting to educate the players each year about concussions. Players also go through a neurological and cognitive assessment after each season.[19]

During Game 2 of the 2016 NBA Finals on June 5, 2016, Kevin Love was placed in the NBA Concussion Protocol.[20]

National Football League

The National Football League's policy was first started in 2007, and injured players are examined on field by the medical team.[16] The league's policy included the "NFL Sidelines Concussion Exam", which requires players who have taken hits to the head to perform tests concerning concentration, thinking and balance.[21] In 2011, the league introduced an assessment test, which combines a symptoms checklist, a limited neurological examination, a cognitive evaluation, and a balance assessment. For a player to be allowed to return, he must be asymptomatic.[22]

National Hockey League

The National Hockey League's concussion policy began in 1997, and players who sustain concussions are evaluated by a team doctor in a quiet room.[16] In March 2011, the NHL adopted guidelines for the league's concussion policy. Before the adoptions, examinations on the bench for concussions was the minimum requirement, but the new guidelines make it mandatory for players showing concussion-like symptoms to be examined by a doctor in the locker room.[23]

"We celebrate the big hit, we don't like the big head hit. There is an important distinction because we celebrate body-checking."[23]
NHL Commissioner Gary Bettman


League Year policy first introduced Year baseline testing occurred Year current policy became effective First step after injury Person who approves/denies player to return Person who decides player return
NFL 2007 2008 2009 Evaluation by medical team Medical staff Medical staff/Consultant
MLB 2007 2011 2007 Evaluation by an athletic trainer using National Association Guidelines Medical staff Head physician/Medical director
NBA Never Never Never Depends on team Depends on team Depends on team
NHL 1997 1997 2011 Neuropsychological evaluation by team doctor off rink Team doctor Team doctor
MLS 2011 2003 2011 Evaluation by medical team Team physician Team physician/Neuropsychologist
NASCAR 2003 2003 2003 Ambulance to infield care center NASCAR NASCAR

Concussions in other sports

American football

American football causes 250,000 concussions annually, and 20% of high-school football players experience a concussion every year.[24][25] In 2000, researchers from the Sports Medicine Research Laboratory at the University of North Carolina at Chapel Hill analyzed 17,549 players from 242 different schools. 888 (5.1%) of the players analyzed have at least one concussion a season, and 131 (14.7%) of them have had another concussion the year later. Division III and high-school players have a higher tendency to sustain a concussion than Division II and Division I players.[26] In 2001, the National Football League Players Association partnered with the UNC to determine whether professional football players suffer any health effects after any injuries, although the findings were criticized by the NFL for being unreliable due to being based on self-reporting by the players.[27]

Association football

Association football— also known as soccer— is a major source of sports-related concussions around the world. Even though 50-80% of injuries in football are directed to the legs, head injuries have been shown to account for between 4 and 22% of football injuries. There is the possibility that heading the ball could damage the head, as the ball can travel at 100 km/hour; although most professional footballers have reported that they experienced head injuries from colliding with other players and the ground.[28][29] A multi-year study by the University of Colorado published in JAMA Pediatrics confirmed that athlete-to-athlete collisions that occur during heading, not impact with the ball itself, is generally the cause for concussion.[30]

A Norwegian study consisting of current and former players of the Norway national football team found out that 3% of the active and 30% of the former players had persistent symptoms of concussions, and that 35% of the active and 32% of that former players had abnormal electroencephalogram (EEG) readings.[31]

During the 2006-07 English Premier League season, Czech goalkeeper Petr Čech suffered from a severe concussion in a match between his club Chelsea and Reading. During the match, Reading midfielder Stephen Hunt hit Čech's head with his right knee, knocking the keeper out.[32] Čech underwent surgery for a depressed skull fracture and was told that he would miss a year of playing football. Čech resumed his goalkeeper duties on January 20, 2007 in a match against Liverpool, now wearing a rugby helmet to protect his weakened skull.

On November 2, 2013 in a match between Tottenham and Everton, Tottenham goal keeper Hugo Lloris sustained a blow to the head by on -coming player Romelu Lukaku's knee. The blow left Lloris knocked out on the ground. Reluctantly manager Andre Villas Boas decided to leave the player on after regaining consciousness and having passed a medical assessment. This broke the rules of the PFA, which state that any player who has lost consciousness must be substituted.[33]

There has been a widespread debate on protective head gear in soccer. Known as a sport associated with intricate footwork, speed, and well-timed passes, soccer also is classified as a high- to moderate-intensity contact/collision sport, with rates of head injury and concussion similar to those seen in football, ice hockey, lacrosse, and rugby. While the benefits of helmets and other head protection are more obvious in the latter sports, the role of headgear in soccer is still unclear.[34]

There are clear rules from FIFA regarding what to do when a player gets a concussion. FIFA's guidelines say that a player who has been knocked unconscious should not play again that day. The rules do however allow for "a transient alteration of conscious level" following a head injury, which says that a player can return to play following assessment by medical staff. The rules also state that a player who is injured with head damage is not to be played for five days.[33]

Among children and teenagers

A growing topic is concussions in girls' soccer, predominantly among high-school girls. Studies show that girls are reporting nearly twice as many concussions as boys in the sports that they both play. The number of girls suffering concussions in soccer accounts for the second largest amount of all concussions reported by young athletes.[35] In 2010, more high school soccer players suffered concussions than basketball, baseball, wrestling, and softball players combined, according to the Center for Injury Research and Policy.[36] According to a study in the JAMA Pediatrics medical journal, many girls do not getting necessary care and prevention regarding concussions, and 56 percent of players (or their families) reporting concussion symptoms never sought treatment.[37]

According to a 2012 study published by ScienceDirect, soccer has the highest injury rate per athlete-exposure among 7- to 13-year-old children.[38]

Auto racing

The death of Dale Earnhardt at the 2001 Daytona 500, along with those of Kenny Irwin, Adam Petty and Tony Roper in 2000, and serious injuries sustained by Steve Park in a wreck in September 2001 at Darlington, led to NASCAR establishing numerous policies to assist in driver safety, such as the introduction of the Car of Tomorrow. Drivers were eventually instructed to wear both head and neck restraints, and SAFER barriers have been installed on racetrack walls, with foam-padded supports on each side of the helmet that would allow a driver's head to move in the event of a crash. Despite this, 29 identified concussions occurred between 2004 and 2012.[39]

In 2012, when Dale Earnhardt, Jr. suffered a concussion after being involved in a crash at the end of the Good Sam Roadside Assistance 500 at Talladega, NASCAR expressed consideration in adding baseline testing to its concussion policies. NASCAR was one of few motorsport organizations that do not have baseline testing,[40] though that ended in 2014, as baseline testing started being performed at the start of the seasons.[41]


In the 2005 high school basketball year, 3.6% of reported injuries were concussions, with 30.5% of concussions occurring during rebounds.[42]


Despite boxing's violent nature, a National Safety Council report in 1996 ranked amateur boxing as the safest contact sport in America.[43] However, concussions are one of the most serious injuries that can occur from boxing, and in an 80-year span from 1918 to 1998, there were 659 boxers who died from brain injury.[44]

Ice hockey

Ice hockey has also been known to have concussions inflict numerous players. Because of this, the NHL made hockey helmets mandatory in the 1979–80 NHL season.[45] According to a data release by the National Academy of Neuropsychology's Sports Concussion Symposium, from 2006 to 2011, 765 NHL players were diagnosed with a concussion.[46] At the Mayo Clinic Sports Medicine Center Ice Hockey Summit: Action on Concussion conference in 2010, a panel made a recommendation that blows to the head are to be prohibited, and to outlaw body checking by 11- and 12-year-olds. For the 2010–11 NHL season, the NHL prohibited blindside hits to the head, but did not ban hits to the face. The conference also urged the NHL and its minor entities to join the International Ice Hockey Federation, the NCAA and the Ontario Hockey League in banning any contact to the head.[47]

The NHL has been criticized for allowing team doctors to determine whether an injured player can return to the ice, instead of independent doctors.[48]

Rugby union

Concussions are also a significant factor in rugby union, another full-contact sport. In 2011, the sport's world governing body, World Rugby (then known as the International Rugby Board, or IRB), issued a highly detailed policy for dealing with injured players with suspected concussions. Under the policy, a player suffering from a suspected concussion is not allowed to return to play in that game. Players are not cleared to play after the injury for a minimum of 21 days, unless they are being supervised in their recovery by a medical practitioner. Even when medical advice is present, players must complete a multi-step monitoring process before being cleared to play again; this process requires a minimum of six days.[49] In 2012, the IRB modified the policy, instituting a Pitchside Suspected Concussion Assessment (PSCA), under which players suspected of having suffered concussions are to leave the field for 5 minutes while doctors assess their condition via a series of questions. Players who pass the PSCA are allowed to return to play.[50]

However, an incident during the third Test of the 2013 Lions tour of Australia led to criticism of the current protocols. During that match, Australian George Smith clashed heads with the Lions' Richard Hibbard and was sent to pitchside. According to ESPN's UK channel, "despite looking dazed and confused, Smith passed the PSCA and was back on the field minutes later."[50]

In 2013, former Scotland international Rory Lamont charged that the current concussion protocols can easily be manipulated. A key part of the current protocols is the "Cogsport" test (also known as COG), a computer-based test of cognitive function. Each player undergoes the test before the start of a new season, and is then tested again on it after a head injury, and the results compared, to determine possible impairment. According to Lamont, some players deliberately do poorly on the pre-season test, so that they will be more likely to match or beat their previous results during play.[51]

Lamont was also critical of the PSCA, noting:

The problem with the PSCA is a concussed player can pass the assessment. I know from first hand experience it can be quite ineffective in deciding if a player is concussed. It is argued that allowing the five-minutes assessment is better than zero minutes but it is not as clear cut as one might hope. Concussion symptoms regularly take 10 minutes or longer to actually present. Consequently the five-minute PSCA may be giving concussed players a license to return to the field.[51]

The Concussion bin was replaced by the head bin in 2012 with the players assessment taking 10 minutes.[52]If concussed the player must then Recover by just returning to general activities in life, then progressing back to playing. Returning to play, must follow the Graduated Return to Play (GRTP) protocol, by having clearance from a medical professional, and no symptoms of concussion

Female sports

Numerous reports have indicated that female athletes suffer more concussions than male athletes.[53] A December 2008 report states that 29,167 female high school soccer players in the United States suffered from concussions in 2005, compared to 20,929 male players. In high school basketball, 12,923 girls suffered from concussions while only 3,823 boys did. Girls also sustained more concussions in softball, compared to boys in baseball.[54] Female athletes also had longer recovery times than males, and also had lower scores on visual memory tests. Girls also have longer recovery times for concussions, which may be due to a greater rate of blood flow in the brain.[55]

Women's ice hockey was reported as one of the most dangerous sports in the NCAA, with a concussion rate of 2.72 per 1,000 player hours. Even though men's ice hockey allows body checking, while women's ice hockey does not, the rate of concussions for men is 46% lower, at 1.47 per 1,000 player hours. College football also has lower concussion rates than women's hockey, with a rate of 2.34 per 1,000.[56]

Women’s basketball is one of the women’s sports with the highest risks of getting a concussion. Women have a greater risk of getting a concussion by dribbling/ball handling rather than defending. Also it was found that female college basketball players typically receive concussions during games rather than practices.[57]

Prevention efforts and technology

There have been numerous attempts at preventing concussions, such as the establishment of the PACE (Protecting Athletes Through Concussion Education) program,[58] which works with the imPACT system, which is currently used by every NFL and some NHL teams.[59] In 2008, the Arena Football League tested an impact monitor created by Schutt Sports called the "Shockometer", which is a triangular device attached to the back of football helmets that has a light on the device that turns red when a concussion occurs.[60] Riddell has also created the Head Impact Telemetry System (HITS) and Sideline Response System (SRS) to record the frequency and severity of player hits during practices and games. On every helmet with the system, MX Encoders are implemented, which can automatically record every hit.[61] Eight NFL teams had originally planned to use the system in the 2010 season, but the NFL Players Association ultimately blocked its use.[62] Other impact-detection devices include CheckLight, by Reebok and MC10.,[63] and the online test providers ImPACT Test, BrainCheck, and XLNTbrain which establish cognitive function baselines against which the athlete is monitored over time. The CCAT online tool developed by Axon Sports is another test to assist doctors in assessing concussion.

Media coverage

In 2012, film producer Steve James created the documentary film Head Games, interviewing former NHL player Keith Primeau, and the parents of Owen Thomas, who hanged himself after sustaining brain damage during his football career at Penn.[64] The documentary also interviewed former athletes Christopher Nowinski, Cindy Parlow, and New York Times reporter Alan Schwarz, among other athletes, journalists, and medical researchers.[65]

League of Denial was a 2013 book by sports reporters Mark Fainaru-Wada and Steve Fainaru about concussions within the NFL. The American documentary series Frontline covered the topic in two episodes, one based on the book and also called "League of Denial",[66] and the other called "Football High"[67] Political sports journalist Dave Zirin has also covered the topic in detail.[68]

See also


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