Medical Examiner

FIFA’s Rule Changes Won’t Solve Soccer’s Concussion Problem

Concussions were a fixture in the tournament four years ago and likely will be again.

Jerome Boateng grimaces as he heads the ball.
Germany’s Jérôme Boateng heads the ball during the 2014 FIFA World Cup final football match between Germany and Argentina at the Maracanã Stadium in Rio de Janeiro on July 13, 2014. Photo illustration by Slate. Photo by Odd Andersen/AFP/Getty Images.

Starting Thursday, billions of people around the globe will watch the World Cup, tuning in for its drama and unexpected moments, like Costa Rica’s fairy-tale run to the quarterfinals last year or Brazil’s humiliating 7–1 loss to Germany in the semifinals. But as I complete my neurology rotations this month as part of my third year of medical school, I am having a harder time just enjoying the sport. Concussions, perhaps unsurprisingly, were a fixture in the tournament four years ago. A research letter published in the Journal of the American Medical Association last summer found that the 2014 World Cup had 81 head collisions in total and 67 of those—about one per game—involved players with two or more concussion symptoms. Among the sufferers were the United States’ Clint Dempsey, Uruguay’s Álvaro Pereira, Argentina’s Javier Mascherano, and perhaps most memorably, Germany’s Christoph Kramer, who soldiered on for 15 minutes after his concussion in the World Cup final before the German medical team finally helped him off the field. Kramer later admitted that he had no recollection of the match itself.

Frustratingly, concussion protocols were not followed in the majority of cases. FIFA, soccer’s global governing body, weathered severe criticism about its concussion management practices after that tournament. The criticism only intensified after a high-profile concussion in the Women’s World Cup the following year. Hoping to avoid another public relations disaster, FIFA is introducing three rule changes for referees and doctors for this month’s tournament: First, referees will be allowed to stop games for up to three minutes so medical teams can better assess players suspected of having concussions. Second, FIFA has mandated that team physicians have the final say on whether a player can stay in a game. And third, it will allow a second team physician to have access to in-match video replays of player injuries, to assist with decision-making off the pitch.

It’s encouraging to see FIFA offer a concrete response to the concussion problem, but it’s difficult to see how any of this will change the status quo. The JAMA research letter found that medical teams already took between 15 and 180 seconds to assess head injuries in the most recent World Cup, rendering FIFA’s first rule change meaningless in practice. And besides, most experts recommend that players with any suspicion for concussion undergo a neurologic exam that generally takes 10 minutes to perform. The other two rule changes will likely also be pointless. Even if team physicians make final decisions about player participation, nothing is being done to protect medical teams from pressure by coaches to keep players in the game or to eliminate their own conflicts of interest to do the same.

To be fair, concussions can be difficult to diagnose. There’s no classic presentation or (for now) a clear biomarker to measure, and more benign conditions, like migraines, or dangerous ones, like epidural brain hemorrhages, can mimic concussions. In addition to a good clinical intuition, correctly diagnosing a concussion can require a physical exam and brain imaging, which can’t be obtained seamlessly in the middle of a game.

Yet the stakes can’t be higher for players. Untreated concussions are associated with both short- and long-term risks, like post-concussive syndrome and chronic traumatic encephalopathy. Simply put, a concussion protocol that errs on the side of caution is well warranted if the goal is player safety.

There’s even growing support for this from the soccer community, including some former players. Since the 2014 World Cup, others have joined the handful of figures in the game, like player-turned-commentator Taylor Twellman (whose career was cut short by concussions) in publicly discussing this invisible injury. After threat of a class-action lawsuit by soccer parents in California, the U.S. Soccer Federation banned headers for players younger than 10 years old, and the organization is exploring other policies to promote player safety. In the U.K., Alan Shearer—the English Premier League’s all-time top goal scorer—just released a documentary about his personal journey to better understand emerging links between chronic head injuries and dementia in the beautiful game. Across sports in general, groundbreaking reporting and cutting-edge research over the past few years have pressured sports leagues, particularly the NFL, to rethink how they handle concussions. And mounting evidence continues to link soccer to chronic, downstream health risks of head injuries.

So what could FIFA do instead? Basically, anything else. It could borrow from the stricter NFL concussion protocols and give independent neurologists access to video replays, allowing them to assess potential head injuries and help make decisions about keeping a player on the pitch. FIFA could also fine national teams that don’t comply with the guidelines, like the NFL did to the Seattle Seahawks in December. The world players’ union, FIFPro, has also long advocated for a fourth concussion substitution in addition to the three substitutions per game already granted to teams. With this rule, a potentially concussed player could be temporarily replaced by a teammate for the 10 minutes experts say are needed to perform a thorough assessment, and then permanently substituted if they don’t return to play within a short, specified time window. It’s true that this rule change could be subject to abuse, creating a temptation for players to feign concussions to give their teams additional substitutions. But in the grand scheme of things, that seems like a small price to pay for player safety.

In the future, FIFA could also consider funding research into managing concussion injuries in soccer. Thinking bigger, it could introduce more serious changes to soccer’s governing laws; some have called for banning headers for all age groups given that they’ve been tentatively linked to chronic brain injuries in former players.

One has to wonder why FIFA’s changes to its concussion protocol are so feckless. It may be a cultural issue: The Bundesliga, the German professional soccer league, posted a video in 2017 joking about a head clash involving Kramer, branding him “the headache hero.” Or maybe it comes down to money. FIFA may feel pressure from major sponsors to keep players on the pitch for as long as possible, especially in later stages of the tournament. And maybe the purists are weary of introducing sweeping changes to the game.

But sports are living and breathing entities, and soccer is no exception. Since it was created in 1863, its rule-makers have added the goal kick, the offside rule, jersey numbers, standardized pitch sizes, and goal-line technology. The sport has also dared to innovate imperfectly, experimenting with many rules now extinct, like the dreaded golden goal. Soccer has the capacity to evolve to better address concussions. The question is when the sport’s governing body will recognize that doing so is essential for the health of the players—from youth teams to World Cup squads—that make the sport so enjoyable to watch in the first place.