Premier League Adopts Stricter Concussion Protocol

The debate about how to best handle head injuries in soccer became more inflamed during this summer's World Cup, when fans witnessed multiple incidents in which players clearly suffered serious blows to the head yet quickly returned to the field. Now, with the top domestic leagues in Europe set to begin their new seasons, England's Premier League has announced changes to its in-game injury protocols.

Effective immediately, the Premier League will require that any player who has a "confirmed or suspected period of loss of consciousness" on the field must be removed from the game and forbidden to return. More important, the league is now mandating that a team's doctors - and not coaches or the player himself - will be unilaterally empowered to determine whether the player was knocked out and, if he was not, whether he is fit to continue. Clubs will also be required to perform baseline cognitive testing on players before each season.

Critics note that, even with the new regulations, it is still a team employee - the doctor - making the call on whether a player can keep playing. The new rules do require that Premier League clubs have a third doctor present at each game who will be stationed in the tunnel between the locker room and the field. That doctor will monitor play and also utilize video replay to help identify players who may have suffered head injuries.

The so-called tunnel doctor will be a significant presence in identifying when players have lost consciousness, though the doctor will also be paid by the home club and not the league.

"My biggest concern right when I saw the announcement was there not being a 'neutral' doctor making the decisions because you still have the conflict of interest when a doctor being paid by a team makes personnel decisions," said Taylor Twellman, a former U.S. national team player whose career was cut short by the effects of multiple concussions.

Twellman has become an outspoken advocate for reform with regard to the care of players who suffer head injuries. He added that it will be difficult for team physicians not to feel pressure from fans or other team members if he has to evaluate a star player in an important game.

"What happens if a team doctor is overcautious?" Twellman said. "You know there will still be pressure on doctors to keep best players in" the game.

In a sport that is notoriously slow to change, however, the Premier League's modifications are an improvement on past practices. Last season, the league was harshly criticized after an incident involving Tottenham goalkeeper Hugo Lloris. Lloris clearly lost consciousness following a collision with an opposing player in a league game against Everton but, after receiving treatment for just a few minutes on the field, continued to play.

Then, during the World Cup, there were at least three incidents in which players appeared to suffer serious head injuries but continued playing. The most notable came during the group stage, when Uruguay's Alvaro Pereira crumpled to the ground after a collision with England's Raheem Sterling.

Pereira was obviously unconscious - several players motioned frantically for trainers to hurry onto the field and help their supine teammate - and it seemed inevitable that he would be replaced. But after being revived, and after Uruguay's team doctor had signaled for a substitute to get ready, Pereira argued vociferously with team officials and persuaded them to let him remain in the game. (Uruguay won 2-1.)

Similarly, Germany's Christoph Kramer lost consciousness early in the World Cup final against Argentina but returned to the field before being replaced about 10 minutes later. It was later revealed that Kramer was so dazed that, during play, he asked the referee whether the game that was going on around him was in fact the championship match.

In both instances, if the rules now in place in the Premier League were enforced the players would not have been allowed to risk further injury. Yet most leagues around the world do not have clear-cut policies in these situations. Pereira was recently knocked out again, during a Brazilian league game; again, he returned to the field minutes later.

The main sticking point in most discussions about how to handle head injuries in soccer is the sport's limit on substitutions. Teams are allowed only three substitutions per game, and for that reason coaches are often loath to make one for an injured player, particularly early in a match.

Some have proposed that teams should be granted an additional substitution for a player who suffers a head injury, though that has raised questions about potential manipulation as well as the incongruous nature of allowing an extra sub for one type of injury but not another.

Twellman said he has wondered if it would be effective to allow teams an extra substitution in the case of a head injury but require the substituted player to then sit out for an additional period (say, a week), presumably limiting the potential for clubs to take advantage of the allowance.

"I am not sure what to make of the substitution dilemma because I understand both sides," he said. "I just know I would love to see advancement on substitutions because it would eliminate any anxiety from coaches or players who feel like making a safe substitution might be letting their team down."

© 2014 New York Times News Service