Expert view: Concussion in football

With concussion a hot topic in the world of sport recently, Dr Charlotte Cowie, Clinical Director for Perform at St George’s Park, looks at the issue and the possible implications for grassroots football.

Concussion – a traumatic injury to the brain – has been in the news for various reasons recently.

Although it has been an accepted risk of contact sport for many years, doctors have only recently begun to understand the way that it affects the brain and its ongoing function. Many ex-footballers, jockeys and rugby players will recount stories of having been ‘knocked out’ and having got up again and continued training or playing and of course, this is commonplace in boxing.

However, we are starting to recognise that even when a player feels fine after a blow to the head, there are sometimes quite subtle signs that the brain is not functioning as it should do and that it might therefore be dangerous for them to continue playing with reduced function.

One of the most common ways of assessing this in a player after a blow to the head on the pitch is by use of the 'Maddocks' questions. You will often see the pitch side medical team talking to a player and it is likely that they are asking:

1. Where are we?
2. Which half of the game is it?
3. Who scored last in the game?
4. Which team did we play last week?
5. Did we win the game last week?

These questions are good at establishing the degree to which the player’s short and long term memory have been affected, which can be a quick but powerful way of assessing whether the brain is functioning as well as it should or not.

If the player is not able to answer any of these correctly, it is an indication that their memory may have been impaired by the blow to the head and they would usually be removed from play. Other signs that all is not as it should be would be if the player looks dazed or has lost some of his / her co-ordination, visual sharpness or balance.

Most doctors now accept that a player in this condition should be removed from the pitch straight away and this would fit with the currently accepted worldwide guidelines put forward by the Zurich International Concussion Consensus Group in 2013.

The reasons for this are that these early signs may worsen, as sometimes slow bleeding from the head can cause gradually worsening damage to the brain and also because there is evidence that particularly in young athletes, the consequences of a second head trauma soon after a first one can be particularly serious (known as ‘second-impact syndrome’).

We do not yet know the long term consequences of this type of injury, although scientists have in the past talked about ‘punch drunk syndrome’- thought to be the result of repeated knock-downs in retired boxers. It even seems that there may be a genetic component to how severely someone can be affected by concussion.

There is still much research to be done, but one thing that doctors now seem to be agreed on is that even what seems to be a very mild concussion can cause damage at a cellular level, even if the brain subsequently recovers well.

More sophisticated tests involved carefully measuring the functioning of the brain using computerised ‘neuropsychometric’ tests that measure the brain’s reaction time and compare it with baseline results. This is also a good way of monitoring how a player is recovering from a concussion and giving a good indication of when it is safe for him or her to return to training.

In the heat of a match, when adrenaline is high and players want to carry on playing, what seems like an easy decision to stop someone playing can be very complicated and difficult to handle. The more we can educate not just medical personnel, but particularly athletes and coaches that there is nothing ‘brave’ about pushing on through this kind of injury, the safer our players will be.

For those that have a further interest in managing concussion, the 2013 Zurich Concussion statement, the SCAT3 pitch side assessment guidelines and the background to current research have been made free to access from the British Journal of Sports Medicine. We also plan to hold a master class on concussion management later this year at St George’s Park.


Dr Charlotte Cowie is Clinical Director for Perform at St George’s Park. She has an immense wealth of elite football medicine experience, a huge amount of enthusiasm and a passion for sports medicine. Over an impressive 20 year career in sports medicine, Charlotte has been Medical Officer to the English women's football squad, Head of Medical services at Tottenham Hotspur FC and Fulham FC and has gained experience in numerous other sports, including tennis, athletics, boxing and cycling.

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