We Have a Problem: Post-concussion Return-to-play in Football

The opening weekend marked a proud moment for me as a Brighton and Hove Albion fan. The first was a great scoreline, away at a hostile ground and a clean sheet to start the season. The second was more on a professional level as someone who is interested in and researching approaches to concussion in football. New signing Minteh found himself being substituted for an injury that was later reported to be a concussion in the 47th minute. Not ideal for a debutant who had a strong pre-season showing by all accounts. Based on the player’s reaction it was not a decision he was happy with, so you could infer it was affirmative action from the medical team to protect a player. Applause

Fast forward one week and Brighton are preparing for the early kick-off at home against Manchester Utd, a team that have struggled for form against the south coast club. To my amazement Minteh has been name in the starting line up less than seven days after his removal from a match with a concussion. So, has pride come before a fall?

New guidelines from the Football Association (2023) advise that return-to-play after a player has suffered a concussion the earliest opportunity to return-to-play is after seven days – which the day of the Man Utd game would be. There are some exceptional criteria to this as the player must be able to provide an enhanced care setting and the player must meet the essential criteria:

1.??????? No history of complex, significant or recurrent concussion which can be classified by:

a.??????? A prior concussion in the previous twelve months

b.??????? Five or more career concussions

c.??????? Any previous concussion complicated by psychological symptoms

d.??????? Previous concussion with prolonged recovery (>21 days)

2.??????? No evidence on initial assessment, either by video or clinical examination, of the following:

a.??????? Loss of consciousness Convulsion

b.??????? Tonic posturing

c.??????? Balance disturbance / ataxia

d.??????? Clearly dazed

e.??????? Disorientated in time, place or person

f.?????????? Confusion

g.???????? Behavioural changes

h.??????? Oculomotor signs (e.g. spontaneous new nystagmus)

3.??????? Normal SCAT6 recorded at 36-48 hours post-injury.

4.??????? Daily review of symptoms and progressions guided by a healthcare professional.

5.??????? Sign off to return to play from an independent GMC registered doctor on the specialist register for neurology, neurosurgery, sport and exercise medicine or other appropriate speciality with experience in management of sports related concussion.

Failure to meet these criteria mean that return to play is expected to take a minimum 12 days in an enhanced care setting if all goes as well as possible. In a standard setting this extends to 21 days.

Given the player was removed based on an on-field assessment is it not safe to assume he was exhibiting clear signs or symptoms of having suffered a concussion (listed in point 2 above)? An explanation could be that after a full assessment including a test such as the SCAT-6, CAS or GCS for example the player was deemed not to have suffered a concussion as originally thought. This would therefore remove the need to follow a graduated return-to-play protocol.

If the player has experienced a concussion injury the risks of premature return-to-play can be extremely serious. A lot of attention is played to the long-term effects of head injuries including an hypothesised increased risk of developing neurodegenerative disease compared to the general population. However, I expect this is of less concern at clubs which are signing players on contracts usually up to five years in length where the player’s immediate availability is paramount. This has been reflected in research which has demonstrated medical staff experience pressure from coaches, staff and players to return them to play prematurely. The short-term risks can be more immediately serious as suffering a second concussion during recovery can lead to an extended post-concussion syndrome which can be severely debilitative and lead to prolonged absence from play, the worst outcomes are a result of second-impact syndrome which at its worst can cause cardiac or respiratory failure and death.

This may seem a dramatic leap, but the risks are there. If Minteh was found to have suffered a concussion I would hope that the availability of other wingers would alleviate the need to risk a premature return-to-play. I hope more that clinical investigation after his removal from the match found he had not met the criteria to be diagnosed with a concussion.

For more information on assessing and managing concussion in football please see the updated FA guidelines (2023) here.

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