Football Features

Why concussion subs matter – and future steps the Premier League can take to address player safety

By Dr Rajpal Brar

Published: 9:17, 23 December 2020 | Updated: 22:24, 28 November 2022

The management of concussions – medically known as mild traumatic brain injuries (mTBI) to give you a better sense of their medical seriousness – has long been an issue in the football world and has recently come under the microscope in the Premier League due to high profile events such as the vicious clash of heads between Arsenal centre back David Luiz and Wolves striker Raul Jimenez, with the former allowed to play on.

I want to emphasise that I am by no means calling out or implying Arsenal medical lead Dr. Gary O’Driscoll’s assessment was incorrect. That is not my place and I am confident that Dr. O’Driscoll – who is considered one of the leading advocates for player concussion safety – had a detailed rationale for his decision. 

To help address such situations, Premier League clubs agreed to implement additional permanent concussion subs after the international football association board (IFAB) approved such trials. The new rule allows for an allotment of two permanent concussion sub replacements, regardless of how many normal subs have already been made.

The new trial is certainly a start but there’s so much more that can be (and needs to be) done to address player safety following head injuries. Here’s a few key things:

Independent neurologist assessment

The reality of medical decision-making in professional sports is there are competing interests between player safety and team competition. Team-associated medical and training staff certainly do their best to calculate risk and reward but there can be a natural biased lens that comes into play, especially with heat of the moment, high pressure decisions. These are still humans making these decisions, after all.

To alleviate that pressure and potentially muddled decision-making, you can use an independent neurologist to assess the player after head injuries. The National Football League (NFL) has implemented this to excellent effect after their sideline protocols came under intensity fire and scrutiny.

Temporary subs

A true concussion and neurological examination takes upwards of 10 minutes and needs to be conducted in a quiet, distraction-free environment. On the pitch is essentially the last place you want to be conducting concussion testing, perhaps second only to a highway during peak holiday rush hour traffic.

A permanent sub does allow for the proper time and environment but there’s no respite if the player who is taken off is then deemed to not have a concussion. A temporary sub provides a better middle ground option.

Video review

There’s also the option of allowing medical personnel on the sidelines or in the stands to review moments of play on video via tablet playback, either incidents that have just occurred or incidents they potentially missed and want closer inspection of.

The Rugby English Premiership implemented this type of video review and enforcement in 2016 using a technology called myplayXplay.

The overall point of all these changes is, first and foremost, to increase player safety. Secondly, these changes lessen the pressure on medical and training staff to make heat of the moment decisions while increasing the validity and accuracy of their testing. These changes also allow for a more nuanced assessment and review of potential on-field incidents.

Dr. Willie Stewart, a British neurosurgeon who has been a champion for improving head injury assessment in soccer and rugby, summed it all up in this interview with BBC Sport:

“Football doesn’t allow an interchange for a player to be assessed to see if he has a brain injury; doesn’t allow significant time for the medics to assess the player; doesn’t have a video review of events to be able to say if there was a glancing blow on my goalkeeper’s head which I didn’t notice.”

The amount of changes I’ve suggested may appear daunting or seem like overkill but the reality is concussion protocols in football have lagged far behind and remained stagnant for far too long.

It’s critical to swing the pendulum back in the other direction and resolutely address the key issues of basic player safety and health following head contact and injuries, especially as we continue to learn more and more about the pervasive and insidious danger of these mild traumatic brain injuries.

Dr Rajpal Brar, DPT, is a physiotherapist, movement and mindfulness coach. He runs the LA-based wellness and athletic development/performance clinic 3CB Performance, and you can subscribe to his Youtube channel (which posts analyses of Lionel Messi and more) by going here.