Loris Karius' 'alarming' concussion saga sparks urgent warnings from brain experts for football to change protocol
Brain injury experts have warned football to urgently overhaul their medical protocols after the “alarming” and “extraordinary” chain of events following Liverpool goalkeeper Loris Karius’s Champions League final concussion.
The charities Headway and The Jeff Astle Foundation, as well as Taylor Twellman, whose own career was ended by a head injury, told Telegraph Sport that the final decision on whether players stay on the pitch following a suspected concussion should no longer rest with club doctors but an independent medical professional.
Headway, Twellman and Dr Willie Stewart, the neuropathologist who diagnosed Chronic Traumatic Encephalopathy in former England striker Jeff Astle, also all called for football to follow rugby union in introducing temporary substitutions to allow players to leave the pitch for in-depth assessments. They also want the more proactive use of video technology during games, as is the case in American football, to assist doctors, coaches and officials in identifying incidents.
Headway chief executive Peter McCabe questioned the “worrying” circumstances around how Karius completed the Champions League, where his mistakes helped Real Madrid to a 3-1 win, despite taking an elbow to the head and then being diagnosed five days later by doctors in Boston with concussion.
“The best time to diagnose a discussion is when it happens,” said McCabe. “He should have been assessed on the pitch. If that didn't happen, when he came off. If that didn't happen, when he got back to Liverpool, where they have got an excellent neurological centre - the Walton Centre. To leave it that long is extraordinary, it seems to me.”
Karius was assessed by Liverpool’s medical team after the match but, although the goalkeeper had signalled to the referee that he had been struck by Sergio Ramos’s elbow, there was no on-field call for treatment and the incident was only widely picked up following replays. Liverpool have not commented on the precise chronology of Karios’ treatment but, upon learning that he was going to America for a holiday, there was sufficient concern to recommend tests with experts at the Massachusetts General Hospital. Those tests took place on May 31 and, in conjunction with Karius, the concussion diagnosis was released on Monday.
Dr Stewart, who is leading new research into the incidence of neurological disease in football, sympathised with the immediate difficulty of spotting a problem but was damning in his assessment of the wider concussion guidelines.
"It's only with the benefit of hindsight you go back and say maybe that slight blow could have been a significant injury,” said Dr Stewart. “But football is operating in the last century in terms of brain injury management. In its immediate pitch-side management and the way the medics are left to deal with this, they are handcuffed.
"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 say if there was a glancing blow on my goalkeeper's head which I didn't notice. It's unacceptable in 2018 that it should be this way."
McCabe and Twellman believe that the potential severity of the Karius situation could have been grasped with better procedures. “In the biggest game in club football, it is alarming to hear that a player has played nearly half a match with a potential concussion,” said McCabe.
“It strikes me as hard to believe nobody spotted it at the time, when he was showing the referee he had been elbowed. What were the assistant referees’ behind the goal doing?”
Twellman said that it underlined the urgent need for video technology to help medics during games. “If you had an independent doctor with access to all those cameras you can make a more educated decision,” said Twellman. “The reality is he got hit in the head. It’s fact. Sergio Ramos should have been red-carded and Karius should have come off the field.”
Ramos, with whom Mohamed Salah also tangled before being forced off with a shoulder injury, remained unrepentant on Tuesday. "I am only missing Roberto Firmino saying he got a cold because a drop of my sweat landed on him," said Ramos. "Bloody hell, they have given this Salah thing a lot of attention. He could have played if he got an injection for the second half. After that the goalkeeper says I dazed him.”
Uefa are currently reviewing their concussion protocols and, after a rule change by the International Football Association Board, are planning to allow video footage in technical areas.
The Premier League and the Football Association introduced a new ‘If In Doubt, Sit Them Out’ concussion protocol in 2015. There is an additional independent touchline doctor to assist club medics at every game but final decisions rest with club staff. Video technology is frequently used but not mandatory.
In American Football, there is an unaffiliated neurotrauma consultant on each sideline during a game to assist in diagnosing concussion injuries, as well as a certified athletic trainer studying video monitors from the press box.
Twellman, whose own career in Major League Soccer was ended at the age of 28, described football’s various protocols as “eye-candy”. He said: “They don’t truly care. It says it all that, after the World Cup final in 2014, when Cristoph Kramer did not know where he was but played on for 14 minutes, we are no further on. The governing bodies don’t take it seriously enough.”
Headway want to work with football to improve guidelines.
“The independent doctor makes perfect sense,” said McCabe. “Concussion substitutes would also be an entirely sensible way forward. You could bring a player in and the team would not be disadvantaged while they made the assessment. It is common sense.”