ISAKOS: 2019 Congress in Cancun, Mexico

2019 ISAKOS Biennial Congress ePoster #2102


Assessment of Head Collision Events During the 2018 FIFA World Cup Tournament

Ajay Premkumar, MD, MPH, New York, NY UNITED STATES
Kevin X. Farley, BS, Atlanta, GA UNITED STATES
Albert T. Anastasio, BA, Atlanta, GA UNITED STATES
Michael B. Gottschalk, MD, Dunwoody, GA UNITED STATES
John Xerogeanes, MD, Brookhaven, GA UNITED STATES

Emory University School of Medicine, Atlanta, GA, UNITED STATES

FDA Status Not Applicable


We evaluated the efforts of FIFA to adhere to the concussion protocol that has been newly updated during the 2018 World Cup.



The Fédération Internationale de Football Association (FIFA) has long adopted a policy that players showing signs or symptoms of a concussion should have a timely evaluation by a licensed healthcare provider using established assessment tools and should not return to play if a concussion is diagnosed. Sparked by discussions over poor adherence to this policy in the 2014 World Cup, the FIFA Medical Committee made three further changes to their concussion protocol. The incidence, characteristics, and assessment of head collisions during the 2018 World Cup were reviewed to assess compliance with FIFA’s updated concussion protocol.


Four trained reviewers identified head collisions though observation of video footage of all 64 games of the 2018 FIFA World Cup. Similar methodologies have been employed previously to assess sport-related head injuries. A head collision event (HCE) was defined as any event in which a player stopped playing immediately after contact to the head. Observable signs of potential concussion were documented for each HCE. Players with >1 sign were categorized as potentially having a concussion.


During 64 games, 95 players had 115 HCEs in 111 separate incidents (1.79 HCEs per match, 4 incidents involved head collisions for two players, 12 players had >1 HCEs). 25 (21.7%) players showed 0 or 1 signs of concussion, while 90 (78.3%) players showed >1 sign of concussion.
Of the 90 players with >1 sign of concussion, only 33 (36.7%) were evaluated by healthcare personnel (median time of assessment 53 seconds; range 13-253). 39 (43.3%) were solely evaluated by the referee (median time of assessment 14 seconds; range 1-57). 18 (20%) were evaluated by another player or not evaluated at all. Of the 6 players that were ultimately removed from gameplay following a HCE, 3 were initially allowed to keep playing after on-field assessment.
A comparison to published data from the 2014 World Cup indicates no statistically significant difference in the proportion of players who did not receive appropriate assessment by healthcare personnel after showing >1 sign of concussion after a HCE (63.3% vs. 56.7%; P=.402).


During the 2018 World Cup, FIFA’s own concussion protocols were not followed in at least 63.3% of HCEs exhibiting >1 sign of concussion, a rate slightly higher but similar to that of the 2014 World Cup. It appears that FIFA’s concussion policy changes did not lead to enhanced concussion management on the field, and has thus rendered these policy changes ineffective.
When healthcare personnel evaluation did occur, the average length of on-field assessment was less than one minute and not standardized. There are several sideline concussion assessment tools available, used in other professional leagues, that in some cases require at least 10 minutes for evaluation.
Concussion assessment protocols and their implementation by large sporting governing bodies may have widespread effects on officiating, coaching, and play of countless athletes around the world. Players at all levels deserve appropriate healthcare assessment and management after a potential concussion event. Concussion assessment and management in international football continues to have significant room for improvement.