Head Injuries in Football - Notes

Head Injuries in Football

Introduction

  • Increased media attention due to cases of neurodegeneration, specifically Chronic Traumatic Encephalopathy (CTE), in American football, leading to dementia, depression, and suicides.
  • Notable cases during the FIFA World Cup 2014: Alvaro Pereira (Uruguay – England) and Christoph Kramer (Germany – Argentina).
  • FIFA and UEFA initiated a 3-minute rule.
  • Three main topics to be covered:
    • Acute head injuries.
    • Repeated heading in children and its impact on brain development.
    • Chronic Traumatic Encephalopathy (CTE).

Acute Medical Care of Head Injuries

  • Focus on on-pitch management, sideline management, and diagnostic and therapeutic work-up until Return to Play (RTP).

Traumatic Brain Injury (TBI) Definition

  • According to the "International Concussion in Sports Group," TBI is a complex pathophysiological process affecting the brain, induced by sport-related biomechanical forces.

Sport-Related TBI Statistics

  • Approximately 3.8 million sport-related TBIs occur per year in the USA.
  • 70-90% are classified as 'minor'.
  • Women experience TBIs approximately twice as often as men.
  • Competition settings see about 13 times more TBIs than training; in the Bundesliga, the estimated rate is 30 times higher.
  • Underreporting is a significant issue; for example, in Seria A (Italy), 62% of cases are undocumented/unreported because players consider them trivial.
  • Prognosis is generally benign, with 80-90% of cases showing complete remission of symptoms within 7-10 days.

Cerebral Hemorrhage (Brain Hematoma)

  • A general term for bleedings inside the skull (intracranial), inside the brain (intracerebral), or at the meninges (extracerebral).
  • Pressure from intracranial bleeding can cause significant issues.

Types of Cerebral Bleeding

  • Epidural: Outside the dura mater.
  • Subdural: Between the dura mater and arachnoidea.
  • Subarachnoidal: Under the arachnoidea; typically spontaneous rather than traumatic.
  • Intracerebral: Within the brain itself.

Concussion vs. Contusio Cerebri

  • Concussion / Commotio Cerebri / Minor TBI: Impaired consciousness lasting less than 1 hour, with 'no relevant neuronal damage'.
  • Contusio Cerebri: Impaired consciousness lasting longer than 1 hour, indicating substantial brain damage.

Mechanism of Concussion

  • Direct or indirect blow to the head.

Key Symptoms and Complaints with Concussion

  • Impaired consciousness, possibly increasing.
  • Dizziness.
  • Headache.
  • Impaired vision, squinting.
  • Differently sized pupils.
  • Swindle (vertigo) and impaired balance.
  • Cramps or other neurological dysfunctions.
  • Nausea and vomiting.
  • Difficulty finding words.
  • Retrograde amnesia.
  • Visual hallucinations.
  • Dizziness/confusion and impaired memory/balance with or without loss of consciousness.

Concussion in Sport - Changes in Brain Network

  • Disconnection within white matter tracts.
  • Structural network disconnection.
  • Large-scale functional network disruption after minor brain injuries.

TBI Management On-Pitch

  • 3-minute time allowance for clinical examination.
  • Only the team doctor decides about continuation of play.
  • Sideline management: no re-substitution possible.
  • Diagnostic work-up/return to play considerations.
  • Aim: prevent second impact and post-concussion syndrome.
  • "If in doubt, sit it out!" - Jeff Kutcher

Second Impact Syndrome

  • A second trauma to the brain before full recovery from the first.
  • Can cause brain edema (herniation) and pressure increase within the skull.
  • Children/adolescents and young adults are particularly prone.
  • Possible genetic predisposition.
  • Boxing has a higher incidence, followed by American/Australian rules football, ice hockey, and then football (soccer).

Post-Concussion Syndrome

  • Variable combination of:
    • Neurological dysfunctions.
    • Pain.
    • Balance problems (swindle, tinnitus).
    • Psychological and psychosocial problems.
  • Symptom decrease after trauma:
    • 40-50% remain over the first weeks.
    • ~30% over the first months.
    • ~15-20% over the first year.

Return to Play After Concussion

  • Initially, rest in a dark chamber and medical examination.
  • Neurological examination on the next day at the latest.
  • Staged RTP over a minimum of 7 days.
  • If symptoms occur, revert one stage back.

Graduated Return to Play Protocol

  • Stage 1: No activity; symptom-limited physical and cognitive rest; recovery.
  • Stage 2: Light aerobic exercise (walking, swimming, or stationary cycling at < 70% maximum permitted heart rate (MPHR)); no resistance training; increase heart rate.
  • Stage 3: Football-specific exercise (running drills); no head impact activities; add movement.
  • Stage 4: Non-contact training drills (progression to more complex training drills, e.g., passing); may start progressive resistance training; exercise, coordination, and cognitive load.
  • Stage 5: Full contact practice (following medical clearance, participate in normal training activities); restore confidence and assess functional skills by coaching staff.
  • Stage 6: Return to play (normal game play).

Repeated Heading in Children and Adolescents

  • Heading is a unique feature of football.
  • Rule changes in US soccer (heading prohibited < 11 years; limited < 13 years).
  • Studies show some changes in white matter (MRI).
  • Concussions during heading duels are usually due to head-to-head contact.

Chronic Traumatic Encephalopathy (CTE)

  • Neurodegeneration due to repeated concussions and subconcussive blows, leading to dementia, depression, and suicidal tendencies.
  • Well-known in boxing; also relevant in American football, ice hockey, and rugby.
  • Occurrence in football is questionable; few known cases; ~1 concussion per 20 matches and negligible training incidence.

3-Minute Rule

  • Introduced in 2014/15.
  • 3 minutes for decision about continuation of play.
  • Only the team doctor is responsible for the decision, not the player or coach.

Head Injuries during Bundesliga Seasons

  • A graph was presented showing the injury incidence rate per 1000 match hours from 2000/01 to 2012/13, including a red card for an intentional elbow kick to the head.

Incidence Rates Per 1000 Match Hours

  • Data comparing pre- and post-rule change:
    • Total Head Injuries: decreased by 29% .
    • Lacerations/Abrasions: decreased by 42% .
    • Concussions/TBIs: decreased by 29% .
    • Facial/Head Fractures: decreased by 16% .
    • Head Contusions: decreased by 18% .
    • Other Injuries: decreased by 13% .

Video Analysis of Most Frequent Injury Mechanisms

  • Elbow to head: reduction of 23%.
  • Head to head: reduction of 14%.
  • Foot to head: reduction of 29%.

Summary

  • Head injuries are to be taken seriously and are a case for the team doctor.
  • Concussion is a clinical diagnosis; intracranial bleeding has to be ruled out.
  • The largest problem: underestimation!!
  • No too fast RTP!