Concussions in Soccer: Phase 2 — Recovery and Return

Storelli presents part two of "Concussions in Soccer " - a series focused on the recognition, recovery and return phases in managing a concussion. Head injuries, head protection and header protocols have never been hotter topics in the world of soccer. Our medical advisor, Dr. Raymond Rocco Monto, offers a number of head injury facts and best practices to help us make the Beautiful Game as safe as we can.

Continuing from our first installment, Phase 2 addresses Recovery and Return. Here we share insights and best practices for managing a soccer concussion and overcoming the dark side of the Beautiful Game. Read-on and be sure to share this report with friends, family and coaches so that world of soccer can be more informed and better prepared to tackle concussions.

Phase 2: Concussion Recovery

The first thing you need to do is GET YOURSELF OUT OF THE GAME! Immediate removal is the mantra here because your brain is most susceptible to dangerous re-injury immediately after the first trauma. Lab studies show that the brain neurons depolarize after a mild concussion and needs 1-10 days to recover. More severe injuries lead to symptoms that can take weeks to resolve. All players should have a baseline screening (like an ImPact test) so that they can be assessed after for brain injury after a concussion during the season. Although there are many effective concussion recovery protocols, all share the same five basic steps:

Source: Elbin RJ, Sufrinko A, Schatz P, French J, Henry L, Burkhart S, Collins MW, Kontos AP:  Removal of Play After Concussion and Recovery, Pediatrics. 2016, e20160910; doi: 10.1542/peds.2016-0910

Rest — After a concussion you need to rest until ALL of  your symptoms have resolved for at least 24 hours. This period can be as brief as a day or two, or as long as a month depending on the severity of injury. You should discuss the recovery protocol with your doctor and training staff and inform your family, coach, and team of your status.

Mild Concussion — You can now start short 5-10 minute periods of supervised exercise such as walking, swimming, or stationary biking. These exercises help raise your heart rate and symptoms should be closely monitored to check for relapse. If you continue experiencing symptoms, then sorry, but back to step #1 you go. If you are doing OK, continue on. This second stage of recovery usually lasts for several days or until you feel that you’re ready to progress.

Moderate Exercise — Your next milestone begins with the gradual extension of the exercise periods to 10-30 minutes. You can also add light, non-contact soccer drills. You’ll need close supervision at this point to monitor you for subtle residual effects of your brain injury. Repeat cognitive testing is often done at this time to gauge your progress.

Heavy Exercise — This is where you put the pedal to the metal and get going. Still no contact, but you are training, hitting the weight room. You are not out of the woods yet, but your symptoms should be resolved at this point. You should be sleeping normally and feel energetic. If not, you stay in this stage until you do. Remember that repeat head injuries are far more dangerous than the first one and take far longer to recover from. It’s just not worth rushing back - no matter what the reason.

Contact — Ok, so you made it this far and you haven’t had any more symptoms. Now we’re talking. You can now start training with your team in contact drills and small sided scrimmages. Still feeling good? Lucky you, a final concussion screening test and visual check awaits. If you pass them with flying colors, you are finally recovered and can return to return to play.

Phase 3: Return & Prevention

So you did everything right. You recognized you had a concussion. You went through the five stages of recovery and are now symptom free and ready to return to play. What now? How can you prevent another scary injury? Look, we all know you’re not going to stop playing. I get that. So what can you do to protect yourself going forward? 

The first and most obvious thing is to be completely honest with yourself and your teammates about your previous head injuries and DO NOT return until you have completed ALL of the recovery steps. The easiest way to prevent re-injury it to allow full recovery.

Next, make sure you work on getting your neck and upper torso muscles strong since they can help prevent or at least absorb a great deal of contact forces during collisions and jousting with other players. In the gym, this includes seated rows, pull down behind the head, triceps, bench press, and core work.

Source: Kawata K, Tierney R, Phillips J, Jeka JJ: Effect of Repetitive Sub-Concussive Head Impacts on Ocular Near Point of Convergence Int J Sports Med. 2016; 37(5):405-10. doi: 10.1055/s-0035-1569290.

Source: #1 Hanlon EM, Bir CA. Real-time head acceleration measurement in girls’ youth soccer. Med Sci Sports Exerc. 2012; 44:1102–1108. doi:10.1249/MSS.0b013e3182444d7d / 

Source #2: Temoun M, Sadeghi H, Nabaei A, Ksaeian A: The Relationship Between Biomechanical-Antrhopometrical Parameters and the Force Exerted on the Head When Heading Free Kicks in Soccer, Arch Trauma Res, 2012; 1(1):44-48. doi:10.5812/atr.5307.

So the jury remains out on the heading issue. More studies are being conducted to see if these changes are pathological or simply adaptive changes to the stresses of heading. US Soccer, however, is not waiting for more data. Under extreme legal pressure to take some type of action, the organization has banned all heading in youth players under 11. Time will tell whether or not this decreases head injuries in soccer, since most are due to player collisions and not heading.

The biggest unsolved question is whether or not concussive and repeated subconcussive head trauma can lead to the disabling and potentially lethal brain disease, CTE. Although some high profile soccer players likethe Brazilian soccer star Bellini, who led his team to the winning of the 1958 World Cup,have been diagnosed with the condition at autopsy, no firm link has been established.

Still, deep concerns linger. Former US World Cup winner, Brandi Chastain, has  committed to have her brain examined for CTE after she dies. So what should you do about heading now? 

Concentrate on proper technique, keep your neck and torso strong, keep a personal “header-count” at practice (keep it under 10), and pick your moments tactically when heading makes sense. 

Can headgear help take the risk out of heading? With so much at stake here, a great deal of research is in play and answers will come. Should you wait for more data before considering headgear? That’s a call you will have to make for yourself, but I personally would recommend you consider gearing up for the sake of your most important organ.