Temporary substitutions
Leeds United player, Robin Koch suffered a blow to the head whilst playing in a match against Manchester United in the English Premier League. Leeds has insisted that all the current Premier League protocols were followed and that the player passed the on-field concussion screening tests. They added that Koch was told to sit down on the field if he developed any symptoms and he would be substituted. This is what then happened minutes after the incident and assessment.
The incident caused uproar in the British media and prompted the Professional Footballers' Association (PFA) to reiterate its call for the introduction of temporary substitutes. Its view, which is shared by many, is that temporary substitutions allow medical teams "additional time and an appropriate environment to make an initial assessment",which can reduce the pressure for affected players and medical teams "to make quick decisions".
Temporary substitutions to allow for head injury assessments have been part of rugby union since 2016. The provision was already in place for players bleeding or with an open wound, so an extension to include head injury was a logical step.
The evaluation and diagnosis of concussion and concussion-like symptoms are difficult for medical professionals. In the context of professional sport, they are often met with players attempting to mask symptoms and a culture of being seen to ‘run it off’, particularly during a high-profile game.
The idea of temporary substitutions, as stated by the PFA, allows medics more time and a more conducive environment to make an initial assessment. It could also enable the use of additional diagnostic tools, based on the latest technology. This could provide greater objectivity within the assessment and therefore a clearer view of the players' wellbeing and suitability to rejoin the game or not.
It’s important to note that the Premier League and FA do have concussion replacement rules which were adopted in 2021. This was following an International Football Association Board (IFAB), the rule-makers of the game, trial in 2020. The rules permit each team to make two permanent concussion substitutes if players have head injuries. If a player shows no clear signs of concussion they will be allowed to continue but will be monitored by medics on the sidelines. The player will then undergo an assessment at half time or full time to find out the extent of the injury. The opposing team is also allowed to make an additional substitution if a concussion substitute comes on to avoid one side gaining an advantage through fresher legs.
The position that the PFA and others are taking is that the IFAB rules don't work. In their view allowing for temporary substitutions provides better care than an on pitch and half-time or full-time assessment. A huge worry regarding half-time and full-time assessments is that players can suffer additional head impacts while continuing to play. Research has shown that it is often these secondary impacts that are cause for concern. On-field assessment doesn’t allow for the use of comprehensive diagnostic tools and provides a poor environment for medical evaluation. The introduction of temporary substitutions would solve these issues and continue the trajectory of enhanced player welfare across the game.
It seems the debate about temporary substitutions will continue in football. The Premier League and FA have made moves to help develop a safer playing environment for players. But with an emphasis on on-field assessment, football is making the role of medics and the response of players harder. This is increasing the risks to players, which in the light of increased awareness of the consequences of concussion and brain injury simply should not continue, particularly when a relatively simple solution is at hand.