One
incident occurred during the MK Dons—Manchester United League Cup game on
August 26. The other occurred during the
August 31, Leicester—Arsenal Barclay’s Premier League game. I sent email inquiries to Manchester United,
Arsenal, The FA, and the BPL about the incidents. I also sent an email to
Everton about an earlier incident. I did
not hear back from Everton, Arsenal, the FA, or the BPL. I received an
(inadequate) response from Manchester United.
Let me summarize the incidents.
On August 26, 2014, the MK Dons played Manchester United in the league
cup. During the course of that game, Shingi Kagawa received a
bloody nose in a clash of heads with Darren Potter. I was unable to watch
this game because it was not available on TV in the United States.
However, according to the match reports of the game, this collision
occurred in the ninth minute. Kagawa received a bloody nose and left the
field for treatment before returning less than two minutes later. He was
then removed from the game in the 18th minute.
According to the match report, he had a “mild concussion and blurred
vision.” It appears unlikely that during the two minutes of time when
Kagawa was being treated for his bloody nose that he also could have been
subject to a full mandatory examination by the team doctor to determine whether
he had a concussion.
I sent Manchester United an email about this incident, I received the
following response:
Hi Rudy,
Thank you
for your email of the 3rd September.
We obviously
cannot discuss individual player medical details for reasons of confidentiality
but you can rest assured that all procedures were followed correctly in line
with standard accepted practice and FA Guidelines. Manchester United have
always been very vigilant in the management of concussion/suspected concussion
and will continue to be so in the best interests of the players and the sport
as a whole.
Regards,
I
have omitted the name of the person who sent me the email for what are, I hope,
obvious reasons. I responded with a
further inquiry. If I get a response I
will do another update.
Manchester
United claims to have followed the FA Guidelines. Since this was a cup game, I assume that the
FA rules, not the BPL rules, apply. The
FA Medical Regulations contains a great deal about head injuries and
concussions. The first rule is
unchanged since last year and provides:
2.7 Head
Injuries
All Clubs
shall ensure that any Player having left the field of play with a head injury
shall not be allowed to resume playing or training without the clearance of a
qualified Medical Practitioner. The same provision shall apply where a head
injury is sustained in training.
The FA Guidelines on Head Injury and Concussion Management in Football now provide:Head injury management
1. If a head injury occurs, the medical team will enter the field to attend to the player. The referee will signal assent in a match situation.
2. The medical
staff will assess the injured player. If there has been a confirmed or suspected
period of loss of consciousness, the player must be removed from the field of
play, and not be allowed to return. If there is any doubt as to the course of
events, elucidation may be sought from officials or other players. In the event
that there is video replay available pitch-side or in the players’ tunnel, this
could be used to clarify the course of events.
3. Where there is a
head injury, but no loss of consciousness, an on-field or touchline assessment
will take place in line using the SCAT 3 pocket concussion assessment tool: (http://www.fifa.com/mm/document/footballdevelopment/medical/01/42/10/50/130214_pocketscat3_print_neutral.pdf
). This should be a standard part of any pitch-side medical kit. The decision
whether the player is removed from the field should be made by the attending
doctor.
4. If there is any
suspicion of the player having sustained a concussion, they must be removed
from the field of play, and not allowed to return.
5. If the player
has been removed from the field of play because of a suspected or confirmed
concussion, they should be monitored until deemed fit and able to leave the
venue. If in doubt, further opinion from local hospital services should be sought
via the accident and emergency dept..
6. If allowed home,
the player should not be allowed to drive, and should not be left alone, but
with a responsible adult who is instructed that should there be any deterioration
in the players’ condition, urgent medical attention must be sought.
7. The medical
attendant must ensure that the responsible adult is in possession of all
contact details of that medical attendant.
Since
I did not watch the incident, I cannot summarize its details but, assuming
there was no loss of consciousness, Kagawa should have been assessed using the Concussion Recognition Tool (the “Tool”). According
to the Tool:
Concussion should
be suspected if one or more of
the following visible clues, signs, symptoms or errors in memory questions are
present.1. Visible clues of suspected concussion
Any one or more of
the following visual clues can indicate a possible concussion:
Loss of
consciousness or responsiveness
Lying motionless on
ground / Slow to get up
Unsteady on feet /
Balance problems or falling over / Incoordination
Grabbing /
Clutching of head
Dazed, blank or
vacant look
Confused / Not
aware of plays or events
I
do not see how anyone can be properly assessed using the Tool in the less than
two minutes Kagawa remained off the field--while he was being treated for a bloody nose--unless he was showing absolutely no
signs of a concussion. However, it is
hard to believe that he was not slow getting up and/or did not grab his head.
Certainly, if he was assessed, as Manchester United implicitly claimed, the
assessor got it wrong.
During the August 31,
2014, game between Leicester and Arsenal, Jeff Schlupp and Laurent Koscielny
were involved in a clash of heads. I
was watching the game as it happened and, later, rewatched it several more
times. (I reference the game clock in my
description of events.)
The
collision occurred at 11:21. Schlupp was
on the ground holding his head and rubbing it.
The physio arrived by 11:43.
Schlupp was drinking something by 11:52.
He got up slowly by 12:01. He walked
off slowly while touching his head at 12:10.
He was back on the field by 14:42, but, apparently not with permission
from the referee. He jogged back off the
field. The game restarted at 14:52 and
he was allowed back on at 14:53.
Since
Mr. Schlupp was slow to get up and holding his head, a concussion should have
been suspected. Possibly his attempt to
reenter the field without the referee’s permission was evidence of ”confusion”
which the Tool also lists as a reason to suspect concussion. According to the Tool
Any athlete with a suspected
concussion should be IMMEDIATELY REMOVED FROM PLAY, and should not be
returned to activity until they are assessed medically. Athletes with a
suspected concussion should not be left alone and should
not drive a motor vehicle.
However,
Mr. Schlupp returned to play and played well so—quite possibly—he did not have
a concussion. Maybe he was fully
evaluated and cleared during the five minutes before he returned to play—although
I am skeptical.
Mr.
Koscielny did not fare as well. After
the collision occurred at 11:21, Mr.
Koscielny immediately began holding his head and rolling around on the ground. This indicated that he had not lost
consciousness, but was in a great deal of pain.
At 11:45 he was still on the ground and holding his head. Two team physios or doctors (I will call them
physios) looked closely at his head at 12:16.
At 12:44 Mr. Koscielny was holding his left hand on the left side of his
head over his left ear and was clearly in pain.
At
13:30 one of the two physios packed up his stuff and left the field. At 13:55 Mr. Koscielny was holding and rubbing
his forehead while seated on the ground.
At 14:12 a player and a physio helped Mr. Koscielny up. At 14:23 Mr. Koscielny walked off the field with
the physio holding a cloth against the back of his head. At 14:27, the physio and Mr. Koscielny stopped. The physio spoke to Arsene Wenger. Unfortunately, I am not a lip reader so I do
not know what was said but the physio did most of the talking. At 14:43 Mr. Koscielny started to enter the
tunnel and the camera cut away. At
17:31, Mr. Koscielny while wearing a weird cap, jogged onto the field. The announcer stupidly called it courageous. At 18:01, the announcer told us that Mr.
Koscielny was given two staples to the back of his head. A close up of Mr. Koscielny shows that he
seems to be behaving normally.
At
20:28 the announcer says that Mr. Koscielny has gotten rid of the hat. At 21:53, a goal was scored when Mr.
Koscielny did not properly mark his man.
A replay shows that he saw the guy but just did not go to him. At 20:15 the game restarted. At 23:40 Mr. Koscielny jogged back on defense—appearing
to me to be running slower than he should under the circumstances. At 24:21 Mr. Koscielny was walking slowly and
touching his head. At 24:30 the
announcer predicted that he would be substituted out. At 25:35 Mr. Koscielny walked slowly off the
field and at 25:59, he entered the tunnel.
As of now, Mr. Koscielny is on the Arsenal injury list.
It certainly appears that Mr. Koscielny returned to play even
though he had suffered a concussion. Once
again, the new rules failed.
Mr. Koscielny was treated on the field for perhaps a bit over two
minutes. He was off the field and off
camera for less than three minutes.
Thus, the total treatment and evaluation time was no more than five minutes. This seems inadequate since, according to
the Tool, he was showing signs that mandated that a concussion be suspected. He was
slow to get up, unsteady on his feet, and grabbing his head.
Arguably, the rules were followed because he was removed from
play. He just came right back. Maybe he was assessed medically during his
time off the field—while they were giving him the two staples. Of course, the staples were intended to get
him back on the field so, at the very least, there seems to have been a mixed
agenda among the medical staff.
Moreover, the FA guidelines specifically state that “If
there is any suspicion of the player having sustained a concussion, they must
be removed from the field of play, and not allowed to return.“ Since, under the Tool, Mr. Koscielny had to
be suspected of having a concussion, FA rules prohibited his return to play.
The BPL rules appear to be slightly less stringent—although that
may not be intended:
O.22.
Each Team Doctor, physiotherapist, therapist and Medical Coordinator shall,
when present at a League Match or at any other match or at training, carry the
pocket concussion tool (which is set out at Appendix 4A).
O.23. Any Player, whether engaged in a League Match, any other match or in training, who has sustained a head injury, shall not be allowed to resume playing or training (as the case may be) unless he has been examined and declared fit to do so by his Team Doctor or, if he is unavailable, by another medical practitioner. The decision of the Team Doctor or other medical practitioner as to whether the Player is fit to resume playing or training shall be final.
However, the Tool must still be used which means that a player cannot
be returned to play if there is any suspicion of a concussion. I doubt the BPL and Arsenal would claim that
returning Mr. Koscielny was justified because the team doctor had, in less
than five minutes of evaluation and treatment, eliminated all suspicion of
concussion such that it was definitely safe to return Mr. Koscielny to the
field of play.
This is not a trivial matter. Both Mr. Koscielny and Mr. Kagawa
and, perhaps, Mr. Schlupp, were risking their lives by continuing to play. There is something called Second Impact Syndrome. (Also, here and here.)
This can occur when a person who has not fully recovered from a concussion
suffers a second head injury. It can be
fatal or severely debilitating.
Mr. Koscielny, in particular, was at risk because his job as a defender
involved heading the ball. In fact, the
goal Arsenal gave up was one that he should have been in position to head
away. Perhaps his failure to be in
position saved his life.
Presumably, the new rules were designed to prevent players with
concussions from returning to play. Yet,
just three weeks into the new season, two players with concussions have already
returned to play. Obviously, I cannot
know whether the new rules were followed and the doctors just made mistakes or whether
the new rules were ignored, but neither possibility is satisfactory. No doctor should ever be called upon to make
a definitive determination that no concussion exists in just a matter of
minutes following a serious head injury.
That is simply impossible.
In the real—not professional sports—world concussion diagnosis takes
time. It is a process that extends over
hours, if not days. (See here and
here.) Football should not pretend that
a proper examination can be performed in a hurry while under pressure to get a player
back on the field.
If the new concussion rules were ever intended to be anything more
than a publicity stunt, the FA and the BPL need to take action. Neither Manchester United nor Arsenal
protected their player as the new rules required. They should be punished. More importantly, the authorities need to
take steps to ensure incidents like these do not happen again.
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