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7 Nov, 13 | by Karim Khan

(A full version of the Daily Mail publication, page 75, November 7). The Daily Mail @DailyMailUK is doing a tremendous service to improve concussion awareness and player management. Kudos Daily Mail.

Now that the dust (if not Hugo Lloris’ scrambled brain) has settled on the Spurs keeper’s knock to the head on Sunday, let’s review the situation and ask what we can learn. Let’s remember that the focus must be on what is best for this player, and sportsmen and women the world over


  • Lloris was clearly concussed. He was knocked out, was wobbly on his feet and in his manager’s own words after the game “Hugo still doesn’t recall everything about the incident”
  • The Spurs doctor (who is highly regarded and was commended for his work on resuscitating Fabrice Muamba) wanted the player removed from the pitch. I have looked at the TV coverage numerous times and he clearly signals that the player should go off. In fact Villas-Boas admitted as much after the match when he said “the medical department was giving me signs that the player couldn’t carry on because he couldn’t remember where he was” and that “he went against medical guidelines to keep the goalkeeper on the pitch”.
  • The decision to keep the player on the pitch was solely the Managers. He admitted that after the game “’It was my call to delay the substitution, you have to make a decision in situations like this”
  • Loris had a CT scan performed after the game and the club’s website said “The Club can confirm that Hugo Lloris underwent a precautionary CT scan and was given the all-clear and travelled back to London last night”
  • A CT scan is performed to rule out more serious head injury. It cannot exclude concussion which probably explains why the Spurs statement said given “the all-clear” which in reality was from serious head injury but the media interpreted as from concussion
  • Despite the clear cut evidence of concussion and the Manager’s admission that he was responsible for the decision, Spurs changed their tune the following day presumably on advice from the club’s PR department (otherwise known as the “Protect the manager at all cost department”)
  • Their Head of Sports Medicine, physiotherapist Wayne Diesel was quoted as saying “Once the relevant tests and assessments were carried out we were totally satisfied that he was fit to continue playing.”
  • Spurs have a Europa League game on Thursday, 5 days after the Everton game
  • The most recent World Concussion meeting was co-sponsored by FIFA and held at the FIFA headquarters in Zurich last November. The Consensus Statement from that conference published in March this year is quite clear on management guidelines for concussion
  • Regarding return to play (RTP) on the same day, it states it was unanimously agreed that no RTP on the day of concussive injury should occur”.
  • Regarding a graduated RTP following concussion “RTP protocol following a concussion follows a stepwise process as outlined in table 1. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 h so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24 h period of rest has passed”.





  • Following the recommended protocol, the minimum time before returning to play is 6 days assuming that the player is totally asymptomatic (no headaches, nausea, “foggy” feeling etc) the day after the incident and right through the rehabilitation
  • Most Premier League clubs would also perform a computerised neuropychological test at the end of the rehabilitation process to confirm full recovery
  • The Spurs Manager explained his decision to over-rule the club doctor on this basis “I made the call to keep him on the pitch because of the signs he was giving. When you see this kind of assertiveness from the player it means that he is able to carry on. He was determined to continue and looked concentrated, driven and focused enough for me not to make the call to replace him. The saves he made after the incident proved that right”.
  • The Manager was overly influenced by the player, rather than the expert medical opinion. The fact that Lloris made some good saves after continuing is not relevant, as it is the long term effects of playing concussed that are a concern. There are plenty of historical precedents for players playing quite effectively immediately after a concussion. It does not justify the decision.
  • To be fair to the Manager, the medical profession’s stand on the management of concussion has changed over the past few years and the Manager may not be aware of this
  • Previously concussion was thought to be a self-limiting relatively benign condition. In the past few years there is increasing evidence of long term brain problems in retired footballers. Most of the research has come from the NFL who recently settled a lawsuit form a large group of retired players for $750 million (without admitting any guilt).
  • Clearly we as a profession have not succeeded in educating football club managers as to the change of attitude and the new protocols
  • Football in the UK would be wise to follow the lead of the English Rugby Union who have summoned all their coaches to Twickenham this Thursday to hear the latest on the management of concussion.
  • When a player is suspected of being concussed, he should be immediately removed from the field of play and assessed to determine whether he indeed has concussion. This assessment, which should ideally be done in the medical room, takes approximately 5 minutes. See SCAT3 (Free). As a result the other football codes have introduced a temporary substitution which can be made while the player is being assessed. In rugby this is a 5 minute period, in Aussie Rules football it is 20 minutes. Soccer needs to consider something similar.

What now?

The short term dilemma for Spurs is whether Lloris plays tonight (Thursday night). They have put themselves in a difficult position. If he plays, then in addition to their breach of concussion protocol on Sunday, they will be breaching the RTP protocol which requires a minimum of 6 days graduated rehabilitation

  • If they rule him out, then they are admitting that he was concussed and that they were wrong to allow him to continue playing
  • If that PR department had been doing its job they would have said that they had always planned to play their No 2 goalkeeper on Thursday and got out of it that way!!
  • The team doctor has the expert knowledge and is the one person who has the player’s health as his/her primary responsibility and therefore should be the sole arbiter of whether a player is concussed.

[BJSM Editor’s note: Credit to Tottenham for clearly following the Zurich Concussion Guidelines here: The Manager is quoted as resting Lloris as a result of Sunday’s concussion. For non-expert readers, when Lloris returns to play should depend on his symptoms (and potentially neuropsychological tests, not a specific ‘time’ . One week is a minimum to progress through the stages (above) but it can take longer if symptoms (headache, unusual tiredness, dizziness) persist. ] Posted on Thursday Nov 7th after the Europa Cup game.

How should this have been handled?

  • It would have been nice yesterday instead of Spurs trying to shift the blame to their (absolutely innocent) medical staff, to hear the Manager publicly state that he had made a mistake, that he was not up-to-date regarding the changes in guidelines for the management of concussion, state his total support for the club’s medical team, and state clearly that he will not interfere in the future.
  • That would have made a positive out of a negative.
  • Instead Villas-Boas has come out and abused those of us who have expressed concern calling us “incompetent”.
  • Sadly he had missed a wonderful opportunity to get the message out there that concussion must be taken seriously.



Who should make the final decision about fitness to keep playing when concussion is suspected? Vote now.

7 Nov, 13 | by BMJ


Mr Villas-Boas stands by his concussion call. “If the manager says it’s not concussion, it’s not concussion”? Mr Villas-Boas – It’s time to apologise for the sake of Hugo Lloris and players the world over.

7 Nov, 13 | by Karim Khan

I was really disappointed with what I saw in this report in The Guardian. To see the word ‘incompetent’ linked to the world experts on concussion including FIFA’s neurologist and sports medicine specialist Professor Jiri Dvorak. To the Concussion In Sport Group who has met 4 times over a decade to make concussion the most improved field of management in sports medicine. Mr Villas-Boas had a golden opportunity for good yet it looks like he is digging a bigger hole for himself.

Let’s keep the facts really clear before the ‘spin doctors’ take over.

1. Mr Villas-Boas alone made the decision for Hugo Lloris to stay on the field. Mr Villas-Boas said “He (Lloris) doesn’t remember it so he lost consciousness” (Sunday!). The call always belongs to me is a quote from Mr Villas-Boas. There was no reference to the medical team clearing the player. Mr Villas-Boas specifically made the point that this was ‘his call’. This cannot be undone – no matter how much spin follows now. Mr Villas-Boas claimed it was his responsibility. The critical point. IT’S NOT THE MANAGER’S CALL.

2. Medical teams use a ‘SCAT3’ test to diagnose concussion – Mr Villas-Boas did NOT administer this short test before taking responsibility to keep Hugo Lloris on the field.

3. The call always belongs to me” is a quote from Mr Villas-Boas. That is the thinking that needs to be changed.

4. Great people apologise when they are wrong. “The call belongs to THE DOCTOR is what Mr Villas-Boas needs to say. Mr Villas-Boas has a golden opportunity to prioritise Hugo Lloris’ health and to influence the health of footballers the world over.  That should be the priority.

5. Abraham Lincoln: “How many legs does a dog have if you call the tail a leg? Four. Calling a tail a leg doesn’t make it a leg.”

6. I’m not going to comment on Tottenham’s football operations. I’m not trained in football or football club operations. On that, I defer to experts such as Mr Villas-Boas. It’s the principle of ‘scope of practice’. Doctors, and other clinicians, are trained in concussion assessment and management. That’s why concussion management is their call. #Lawyer’sFieldDayWhenManagersMakeConcussion”MyCall”.

7. A reminder for Tottenham Risk Management Department. The NFL just settled a concussion suit for $765 million. Can you imagine the court case in 2025….

Lawyer: “Mr Lloris, you say you have persistent headaches and your career was cut short after the game at Goodison Park in 2013. Who made the call for you to keep playing in that game?”

Hugo Lloris: “Well that was Mr Villas-Boas”.

Lawyer: “I see, Mr Villas-Boas was a neurologist, a sports physician, someone well versed in concussion management?”.

Hugo Lloris: “Uhh…no, he was our manager, a very good manager.”

Lawyer: “No further questions your honor”.

I hope, for Hugo Lloris sake, that a poor process (Mr Villas-Boas making the call) leads to no harm. But this is a watershed issue for the future Hugo Lloris’ and every woman, man and child who plays football. It’s the health professional’s call.

Come out and share that with the world Mr Villas-Boas. Great men have made important apologies. Football has been good to you. It’s time fpr you to be good for football.


Here’s the link for folks who care about the health of players….


Sorry Mr Villas-Boas. “Concussion call ALWAYS belongs to Doctor.”

4 Nov, 13 | by Karim Khan




The BJSM represents an authoritative voice in sports medicine so it would be negligent if BJSM did not comment on the widely-reported ‘Loris concussion’. We begin by emphasizing that BJSM knows the Tottenham medical team and they are excellent. In 2012, they helped saved Bolton’s Fabrice Muamba’s life on field – and provided a global illustration of world’s best practice.

In my editor in chief role, I also underscore that this blog comment comes without having been at the game between Tottenham and Everton, without having watched the footage, and without having assessed the player.

The focus of this letter is on a media report, with the caveat that media reports can be wrong.

If the media reports are accurate, my respectful point Mr Villas-Boas, would be – ‘Please learn from this incident that the concussion call does NOT belong to you.’  Mr Villas-Boas, the  world concussion experts, including FIFA representatives, met in Zurich in 2012 and agreed that potential concussion incidents need medical assessment. This is in the best interests of player and of coaches. Imagine how a coach would feel if he or she were to overrule a doctor, insist a player return to play, and then watch helplessly as that player bled to death later in the game, or that night at home.

Letting a concussed player return to sport is not validated by how the player performs later in that game; nor does a normal MRI scan mean it was safe for the player to return. An MRI only visualises structure – it cannot measure the complexity of brain function. Many former NFL players with chronic headaches, depression, and suicidal ideas had normal MRIs shortly after their concussion episodes.

An entire BJSM issue, supported by various sporting bodies including FIFA and the IOC is freely available by clicking here.

I cannot pretend to imagine the pressures of being an Premier League coach and I apologise for writing in a public forum. But as BJSM editor, I have a responsibility to my constituency as you do to yours.

This open letter/blog merely comments on what has been attributed to you – “the call always belongs to me”. If this was an inaccurate quote, or out of context, I apologise sincerely in advance. If you agree that medical decisions should be made by your expert medical team then you and I  agree. If you believe that you, as coach, have ultimate medical authority, over and above the medical team, I have a professional responsibility to disagree vehemently. Given how widely this incident has been reported, your quote “the call always belongs to me” needs to be countered strongly in a public forum.

I have worked with many excellent coaches/managers – coaches who have reached the pinnacle in professional and Olympic sports. They unequivocally support the position that the medical team must have the final say in the concussion decision. In other clinical settings, such as after a hamstring strain, ‘return to play’ and ‘availability’ decisions are ‘joint decisions’. The medical team provides input to the player and the coaches/manager make a decision. The very crux of ‘evidence-based practice’ has the ‘patient’ at the centre of decision-making model with options explained by the clinician.

But concussion is different. Because of the player’s mental state, he/she is not any position to make a call. Coaches are not trained to make the call. World Cup Final. Champions League Final. Premier League clincher. It matters not. In suspected concussion Mr Villas-Boas, “the call always belongs to the doctor”.

I’m signing my name as a professional responsibility and I’m happy to discuss this if you feel anything I have said is not respectful or not true. I wish you and your team every success and I underscore what a great medical team you have.  Most respectfully, karim khan.


UK’s Faculty of Sport & Exercise Medicine Call: What is the link between Early Onset Dementia and Contact Sports? Plus 4 key messages – ready for immediate action!

11 Aug, 13 | by Karim Khan

The Faculty of Sport and Exercise Medicine (FSEM) in the UK calls for further research into any possible relationship between early onset dementia and contact sports with a risk of head injury/head impacts.

Research is needed to better understand the way in which brains may be damaged after a sporting head injury and the time course to recovery. The short, medium and long term consequences of head injuries during sport can be far reaching and concussion management in particular needs to be regularly reviewed through international consensus and clear standards adopted across all sports.  A co-ordinated research strategy to establish both the risk of Early Onset Dementia in the general population and the retired sporting population, as well as prospective studies following up players after their playing careers have ended, would be welcomed.

Dr Mike Loosemore Fellow of the FSEM, Consultant at the Institute of Sport, Exercise and Health, University College London and Doctor to The British Boxing Team comments:

“There is an association between serious head injury and dementia; however the evidence of dementia following concussion is not there. There is also the problem of attribution; just because an ex-player has developed dementia does not mean that the dementia was caused by their exposure to a particular sport. So if a patient who has dementia following a severe head injury also played a high impact sport, which group would they be in?”

Whilst the possible long term consequences of head injury are being researched, the Faculty believes that it is important that 4 key messages of concussion management are understood and implemented:

  • The critical importance of recognising and removing the concussed player from play is highlighted, along with the importance of the player not returning to play the same day.
  • The principle of monitoring a concussed player’s progress through a graded return to play only once the player is symptom free is also highlighted.
  • A more conservative approach to the management of the age-group player is being adopted by many sporting organisations. Sports Physicians with expertise in concussion management are uniquely placed to co-ordinate the care of the athlete who has suffered a concussion.
  • Best practice clinical pathways from injury to return to school and play for the concussed player outside of the elite sports setting are not easily accessible in the UK and the Sports Physician with expertise in concussion management is well placed to develop this locally in collaboration with other healthcare professionals.

The Faculty will be working with its Members and Fellows to raise awareness about concussion management and together with other sporting organisations and national governing bodies look to align standards of management.

The Faculty believes that best practice concussion management should be data driven wherever possible and stresses the value of adopting a full an open risk management process where a data driven risk assessment drives practice and is openly communicated to the public and media. Concussion is an emotive topic where strong opinions are often held and injudicious reporting of risk can strongly and negatively impact on player participation rates and could lead to adverse health outcomes.

The BJSM is the primary host journal for the 2013 publication on Concussion in Sport: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012 is available here (Open Access) and has had over 40,000 full-text views.


Click here to view the International Rugby Board’s guidelines for on-field concussion

Click here to view the Rugby Football Union’s concussion guidance and here to access the HEADCASE resource

Notes to Editors:

  •  The Faculty of Sport and Exercise Medicine was launched in 2006 and is an intercollegiate faculty of the Royal College of Physicians of London and the Royal College of Surgeons of Edinburgh
  •  The Faculty has over 550 Members and Fellows, not including medical students
  •  There are around 70 SEM specialists registered with the General Medical Council
  •  The FSEM not only sets standards in SEM but oversees research, training, curriculum and assessment of SEM Doctors, including providing revalidation services
  •  Sport and Exercise Medicine involves the medical care or injury and illness in sport and exercise. It requires accurate diagnoses, careful clinical examination, experience and knowledge of sport and exercise specific movement patterns. SEM practitioners work in a variety of settings across primary, secondary and tertiary care. The specialty has a large scale application in improving the health of the general public through exercise advice and prescription. Further information about the specialty can be found in the Media & Resources section at


Follow FSEM on Twitter @FSEM_UK

Link to FSEM on Linkedin

For further information contact Beth Cameron, PR & Communications for the Faculty of Sport and Exercise Medicine;

Email:, Tel: 0131 527 3498, Mobile: 07551903702



Please use these PPT slides that summarise the 2012 Zurich Consensus statement on Concussion

6 May, 13 | by Karim Khan










HEADLINE FOR THE TIME-POOR: Here is the link to the slides for your presentations, but please don’t alter them without the permission of the Consensus Statement authors.

During the 4th International Conference on Concussion in Sport (Zurich 2012) attendees revised and updated the Consensus Statement. The new 2012 Zurich Consensus Statement builds on previously outlined principles and furthers conceptual understandings. Using a formal consensus-based approach, contributors developed this document primarily for use by a spectrum of Sports Medicine (recreational, elite or professional) physicians and healthcare professionals.

Remember that BJSM is the only place to find the 12 systematic reviews that support the consensus statement. We also have 5 podcasts by Co-leads Paul McCory and Winne Meeuwisse on our podcast page.

An informative PowerPoint presentation, and the main outcomes of the 2012 Conference on Concussion in Sport, is now freely available on the BJSM Education website.

The PowerPoint presentation contains:

  • An outline of the consensus process
  • A description of the definitions used for concussion and traumatic brain injury
  • The evaluation of an athlete suspected of suffering a concussion
  • The management of a concussed athlete
  • The modifying factors that might influence evaluation and management
  • Special populations
  • Prevention
  • And an overview of the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and the Child SCAT3

You are free to use these slides (link here) for your own presentations, but please don’t alter them without the permission of the Consensus Statement authors.

If you wish to insert your own slides to create a customized presentation, please use a different theme, or colour, to distinguish your slides from the ones prepared by the Concussion in Sport Group.


Babette Pluim, Deputy Editor BJSM




Australian Football League considers Concussion Consensus Statement

12 Mar, 13 | by Karim Khan

Interesting take on the Consensus statement from the Zurich 2012 Conference on Concussion In Sport. This paper is Open Access on BJSM and BJSM is the exclusive publisher of the 12 systematic reviews that underpin the Consensus statement. This special issue of BJSM is an Injury Prevention and Health Protection (IPHP) issue of BJSM – supported by the International Olympic Committee.

Click here for the full AFL blog:



Congrats to Paul McCrory and team for the 4th International Conference on Concussion in Sport Consensus Statement

11 Mar, 13 | by Karim Khan


The 4th Consensus Statement on Concussion in Sport (based on the 2012 International Conference on Concussion in Sport, Zurich) is live exclusively on the BJSM site. BJSM will be the only journal carrying 12 review papers that complement the Consensus statement. Table of Contents here. The special issue of BJSM relates to Injury Prevention and Health Protection (IPHP) and the IOC supports 4 such theme issues annually.



Subsequently, many other journals will publish the Consensus statement – this is not something that should be kept ‘exclusive’; the statement will be free at all journals and it will include important ancilliary documents such as the SCAT 3, the Child SCAT, and the CRT – Concussion Recognition Tool for patients and parents. We congratulate the editors of this 4th statement – Paul McCrory, Winne Meeuwisse, and Jiri Dvorak – all members of BJSM’s senior leadership group among their other responsibilities and affiliations.

As the 4th Consensus statement is launched, we note that the 3rd such document received over 55,000 clicks – given the increasing move to mobile web platforms, the 12 member societies that support BJSM alone, and the general increasing attention to the field, this number is likely to be passed rapidly by this 4th document. Ultimately, the importance of this work is in changing management and one only needs to look at the Sidney Crosby ice hockey case and the legislation in the US to recognize that previous Consensus statements have contributed to making sport safer.

The decade of commitment among concussion researchers is one of the success stories of sports & exercise medicine. The collaboration, engagement of key stakeholders (including the IOC and FIFA), hard work of many, consistent purpose, rigorous research, combined with a focus on tools for the athlete (SCAT, CRT) provides an example for those leading the charge in other conditions in our field, and in the health professions generally. Innovation, education, implementation. That would make 3 great themes for BJSM as well!

Drs Paul McCrory and Winne Meeuwisse will launch the 4th Consensus statement in Qatar and Canada, respectively, on Tuesday 12th March. Media can contact them via:

Dr Paul McCrory (visiting Aspetar – Qatar Orthopaedic and Sports Medicine Hospital) [contact today at + (974) 33 67 82 03]

Dr Willem Meeuwisse, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.


Note that Dr McCrory’s home university appointment is:

The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia


Concussion management in England’s FA – better than it appears in new BJSM paper….

10 Oct, 12 | by Karim Khan

E-letter and update by Dr Ian Beasley (FFSEM)

In response to:

Jo Price, Peter Malliaras, Zoe Hudson. 2012. Current practices in determining return to play following head injury in professional football in the UK. Br J Sports Med 2012; 0: 201109068 (Original article). [this paper is Online First and is included in the upcoming November Print Issue of BJSM [BASEM Theme Issue].

There is no doubt that since the first consensus statement on concussion, conceived in Vienna in 2001 (read BJSM summary article here), every sport has raised its game on head injury and concussion management and reviews by the various sports over the years have resulted in updated and improved practice.

Football in this country has been similarly active.  At the behest of the FA medical committee, and as a result of collaboration between an eminent Premier League medical officer, and a Neurosurgeon working in sport, the current FA head injury guidelines were devised.  They were circulated to clubs in November 2009, and have been in use since then.

Since its inception the SCAT 2 form has been included in these guidelines, and is published as part of the head injury guidelines in the FA handbook (1), and on our website (here).

In their study Price et al (2) mention that many club medical officers ‘are not required to demonstrate any expertise in concussion management’.

Medical indemnity providers have insisted for some time that medical practitioners attending sporting events must ensure they are adequately trained to provide appropriate care for their athletes (3).  We would encourage any medical practitioner involved in sport to heed this message.

The initial questionnaires in this study (2) were sent to clubs before the availability of current guidelines. By the time the second batch of questionnaires were sent out, all clubs were in receipt of the current guidelines from the FA.  Hence, by the time conclusions were drawn in this study, they were not contemporary. They do not reflect current practice within professional football.  Nor do they represent the stance of the FA in dealing with this important issue.

In my experience, governing bodies and their medical officers will always be of help when trying to obtain up to date information regarding practice and policy within their respective sports if asked.

1. The FA Handbook, Rules and Regulations of The Association, season 2012-13.
2.  Current practices in determining return to play following head injury in professional football in the UK. Price, J., Malliaras, P., Hudson, Z.  Br J Sports Med 2012;0:1-5
3. MPS issues advice to doctors assisting at sporting events :  07 Jul, 2006. 

Editor’s note – link to the most current consensus document here – the Zurich (3rd) concussion guidelines (>47,00o page views as of October 8th, 2012).

Dr Ian Beasley MBBS, MRCGP, MSc, DIP.Sports Med, FFSEM (UK) is Head of Medical Services Club England Division The FA Group Wembley Stadium, Wembley, London, HA9 0WS

Dr John Orchard on the “metal staples – no local anaesthesia” – discussion. Guest Blog.

18 Aug, 12 | by Karim Khan



 Interchange laws, bleeding and apparently dying players


I am very interested to have read the Blog by Drs Fowell and Earl ( about the use of staples to close lacerations on the side of the pitch in football matches.

I used metal staples like this quite a few times myself in the early 2000s in rugby league and wrote up one of the cases in the BJSM (Orchard JW. Video illustration of staple gun to rapidly repair on-field head laceration.  Br J Sports Med 2004;38(4):e7). Now I still use staples as one of the options for closing wounds in rugby league players, although no longer do I do it on the sidelines. Shortly after the 2003 case (which was subsequently written up) a further case which was far more notorious occurred when I closed an eyebrow laceration on Michael De Vere in a rugby league State of Origin game

This was done on the pitch itself whilst a video refereeing decision was being made, meaning that the player didn’t leave the field – he didn’t miss any playing time at all. The video of the procedure, however, was captured on TV and shown to millions of viewers. The reaction to the vision was that the NRL (National Rugby League) banned the use of the staple gun outside the dressing room, meaning that players have to now leave the field to have a laceration closed.

The issue of management of lacerations is one which not only is of concern to team doctors – who must weigh up both (1) optimal medical treatment of an injury and (2) minimising loss of game time for players – but it now also needs to be a major concern for sporting administrators.

I cover some of the related issues in an Editorial in the August 2012 BJSM (Click here for: Orchard J. More research is needed into the effects on injury of substitute and interchange rules in team sports Br J Sports Med 2012;46:10 694-695). All sporting bodies should engage Medical Directors and medical/injury management concerns must to be prominent when considering existing and proposed new rules. Whether use of staple guns pitchside should be recommended in a sport depends on quite a few factors, including (but not finishing with) whether it will lead to unpleasant images on TV.

Blood management will be influenced by substitution rules

The sports rules for handling blood and the interchange/substitute laws clearly have a major impact on medical management. If the rules allow for “free” interchanges/substitutes for bleeding wounds (as per rugby union), then the player can be treated in the dressing room with minimal time pressure. However, this privilege (‘free’ substitution to respect the bloody player) can also lead to the distortion that it is advantageous for a team to have a player suffer a laceration (as they get an extra interchange in these circumstances). This, of course, is the scenario under which the “Bloodgate” affair arose. If it is disadvantageous for a team to have a player missing from action, then extremely rapid wound closure becomes a valuable priority. The challenge for all sports lies in balancing all of these concerns.

Practical implications of Fowell and Earl’s new data (blog, above)

I suspect that some football team doctors will look at the large case series of Fowell and Earl and decide that under the current FIFA rules (3 substitutes but no interchanges or “blood bins”) it makes sense to use staples on the side of the pitch, without local anaesthetic, for the uncommon scenario (in football) of a head laceration. History is in danger of repeating itself; this practice may be tolerated until children are exposed to it in their living rooms (e.g. by seeing a replay of it being done in an FA Cup final, for example).

More substitutes in football? (soccer)

A benefit of any debate on whether or not to ‘ban’ pitchside stapling in football will be that it should include a consideration about introducing an interchange player to the game itself. If soccer was to allowed 3 substitute players but also 1 roving interchange – the converse of the current ‘bench’ in the AFL (Australian Football League) – then a player could be interchanged off for 5 minutes for stapling/suturing to be done in the dressing room, without penalty to the team. It would also allow the player to be more thoroughly assessed for any co-existing concussion from the same blow to the head. This would fix an uncommon but consistent problem in the sport — how to deal fairly with the bleeding player.

It may also help fix a consistent but far more common problem – the exaggeration of minor injuries. If a player who was tapped on the shins and needed 2-3 minutes to recover was able to be interchanged off the field and temporarily replaced until this recovery, there wouldn’t be as much benefit in “playing dead” to stop the game if the temporary replacement could be made without hurting the team. A hybrid bench of substitute and interchange players (or one with a limited number of interchages rather than substitutes) probably leads to optimal injury management and perhaps even fewer injuries overall.

To close, I contend that the debate about what is best for a sport shouldn’t start with an argument of “this is how it’s always been done” but it should finish with “this is how we will make sure our sport gets the balance right between entertainment, fair play and optimal injury management”.

This Guest Blog relates to the BJSM Blog posted on August 16th – please scroll down.

John Orchard is an Australian sports physician who has worked with numerous professional team sports. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. You can read more at and/or follow @DrJohnOrchard on Twitter


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