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Pro players speak out about the ‘absurdity’ of the concussion protocol in women’s soccer

In September last year, the NFL launched a new protocol surrounding concussions. The  initiative, known as “Play Smart. Play Safe,” now specifies that whenever a player is suspected to have incurred a possible concussion, he must be removed immediately from the field and analyzed by a team physician, as well as an unaffiliated neurotrauma doctor. If either doctor thinks the player may have a concussion, he will be taken to the locker room for a full medical assessment and not be allowed to play the rest of the game if that suspicion is confirmed. If the diagnosis is negative, the player will still be monitored closely for any possible symptoms throughout the rest of the game.

The new protocol also mandates that the NFL must provide two medical spotters who watch games through binoculars and with video replay in order to identify possible concussions.

Last year, in part because of the new protocol, the number of concussions in the league fell by 11.3 percent from 2015.

[More from Excelle Sports: New study shows girls’ soccer has the highest concussion rate of high school sports]

Why bring up the NFL in women’s sports?

The National Women’s Soccer League’s (NWSL) concussion protocol, unlike that adopted by the NFL, relies on a different premise: Players must report if and when they have a possible concussion. The problem with this premise: I can speak from experience that almost no player will report a possible concussion because they want to keep playing. In addition, soccer coaches and trainers often advise players not to report concussion symptoms so they can continue to be used in match play.

In December 2015, U.S. Soccer prohibited heading in youth programs until age 11 after the NCAA reported that concussions are the second most common injury among female collegiate soccer players, affecting 9.2 percent of those who play. (The most common injuries are contusions, or bruises).

Unfortunately, the concussion percentage in soccer is based on the number of injuries that athletes actually report, not necessarily how many they sustain. If you were to ask soccer players how many concussions they have had, the answer is usually indefinite. Oftentimes, you hear, “I’ve had four diagnosed, then I want to say I have had one or two more definitely, but not diagnosed.” That means the percentage of actual concussions in pro soccer, including those undiagnosed, is likely much higher.

What’s more, women athletes are up to 2.1 times more likely than men to suffer from a concussion; they also take longer to heal. While scientists aren’t exactly sure why this is, they suspect hormones may play a role.

All these statistics highlight that the NWSL needs an effective concussion protocol. So let’s look at what the league does have.

According to the league’s current protocol, all players must take an ImPACT test, or computerized concussion-assessment exam, before the season’s starts to establish baseline data. Then, whenever a player is suspected of a concussion, she is given the imPACT test again. If the player fails the test, she must typically wait about a week (more or less, as determined by her trainer’s assessment) to retake the test. When the player finally passes, she goes onto the next phase: headers.

“Day 1, you are to head the ball 8 yards away—five times forward, five times on the right, five times on the left,” Sky Blue FC player Kelly Conheeney, who has suffered multiple concussions, told Excelle Sports of the process. “Day 2, you are now 18 yards away [from the ball], and the same procedure follows: five times forward, fives times on the right, fives times on the left. Day 3, you are to stand 30 yards away and a trainer is supposed to kick the ball for you to head it five times forward, five times left, five times right … It’s absurd—it’s way too many consecutive headers. How long can you last? Seriously.”

Sky Blue’s Kelly Conheeney has suffered multiple concussions as a player. (Rachel Breton)

What this means is that a player suspected a concussion must head a soccer ball 45 times in the course of three days—a protocol that seems to induce or aggravate injury rather than prevent it. After all, when does a women’s pro soccer player ever head the ball 45 times during her entire season, let alone three days?

Conheeney isn’t the only one who recognizes some absurdity in the NWSL’s protocol. Many coaches and players feel that the league’s testing is ineffective, if not counterproductive. For this reason, some coaches tell players not to do the post-concussion header test. What’s more, last year, some players said that their clubs even deflated balls before they were asked to take the header test in order to lessen possible impact.

So if NWSL coaches and clubs can’t abide by the system, doesn’t that scream for a reevaluation?

It seems as though the plot has been lost.

[More from Excelle Sports: New study found CTE in the brains of former professional soccer players]

What the NFL has that the NWSL does not are unaffiliated doctors. The NWSL instead relies on doctors and trainers who work closely with teams and are more likely to listen primarily to what the coaches and players say rather than objectively evaluate player and match-play data. In short, team doctors are more likely to be persuaded when one of their players says they’re fine to play after a concussion, which happens more often than not.

“As a player, your adrenaline can take you through the end of the game and you don’t realize until later [that you have concussion symptoms],” Conheeney said. “That’s happened to me.”

When NWSL players hear how the NFL handles concussions, they are impressed.

“Neutral doctors would be very beneficial and not just for concussions,” Portland Thorns FC defender Kendall Johnson told Excelle Sports. “From experience, I can tell you that there are so many situations where players, especially if they’re highly valued, are pressured to come back [after sustaining a possible concussion] and the doctors, as much as they try to be neutral, get lost in translation, especially for concussions.”

But when it comes to concussions in women’s soccer, feeling “fine” is not enough.

“The hardest thing is that you don’t know where to turn,” Conheeney said. “It’s such a serious injury and it can ruin your whole life. There has to be an understanding among the coaches that if a player has a concussion, they need to be on the same page and [coaches] can’t treat them like, ‘Oh, we need you right now.’”

Manya-Makoski-womens-soccer-concussions
Manya Makoski played professional soccer for years before having to retire due to too many concussions. (Rachel Breton)

Manya Makoski, a former Women’s Professional Soccer and NWSL midfielder, suffered six concussions while playing professionally.

It is the worst injury that I have had to deal with,” Makoski told Excelle Sports. “If you break a leg, you can get surgery, be put in a cast and rehab to recover—it doesn’t affect your life in a major way. But with concussions, it affects all aspects of your life—mentally, physically, emotionally. I was depressed, not feeling right with myself, couldn’t remember information that was given to me and frustrated with the way I was feeling.”  

This year, Makoski had surgery on the occipital nerves in her neck to help alleviate her concussion symptoms.

womens-soccer-concussions-manya-makoski
Manya Makoski shows her scars two days after having nerve surgery due to concussion symptoms. (Rachel Breton)

“For the last [concussion], I saw a neurologist and tried steroid/nerve block injections that didn’t work, so I finally opted for surgery,” Makoski said. “I had occipital nerve decompression and occipital nerve release. Basically all of the damage from my six concussions irritated my nerves, which created the daily migraines I would have. The surgeon took care of those nerves. I am one week out of surgery and I feel great. No migraines!”

Most players I spoke with would love to see the NWSL implement a concussion protocol similar to the one adopted by the NFL. While it may be more expensive to hire unaffiliated doctors to attend every game, over the course of time, how much money would women’s soccer save in medical costs and, more importantly, how many lives would the league save?

Another possible solution that would save the league money and headaches, pun intended, would be to implement initiatives that help prevent concussions from happening in the first place.

What would be cool is to have, as part of any concussion protocol, players pass a neck-strengthening test,” Johnson told Excelle Sports. “For me and many in women’s soccer, [getting concussions] was a lack of neck strength, which is repeatedly seen as one reason why females are more prone to concussion––our necks aren’t as strong as a guys.”

There’s a big elephant that needs to be addressed in women’s professional soccer. The personal accounts shared here are frightening and should concern players, coaches, league administrators and fans alike. Something has to change. Player health should matter more than money, every time.

Ultimately, to protect the life of players is to protect the life of the sport.

Jump To Comments
  • commentprofile

    When I saw Christen Press get popped in the head by a ball last week against Orlando, I kind of wished they would’ve pulled her out. She’s one of the best. Don’t want to see her all concussed and stuff. Come out next time, girl!

  • Soccer AT Society

    The Soccer Athletic Trainers’ Society (SATS) has been made aware of a recent article published by Rachel Breton in Excelle Sports titled “Pro players speak out about the ‘absurdity’ of the concussion protocol in women’s soccer” by concerned members. We applaud Ms. Breton’s efforts to push forth the conversation about concussions and the care that players receive. She makes a few valid points however, there are several statements made about athletic trainers that we feel must be addressed.
    Foremost, we have a significant concern about the statement: “(Athletic) trainers often advise players not to report concussion symptoms so they can continue to be used in match play.” We feel this to be dangerous, inflammatory and unfounded. This false implication that there is broad malfeasance by athletic trainers as well as team physicians erodes public trust in those that have been tasked and held responsible with ensuring player safety. We are not aware of any specific cases or any research that supports this statement in any fashion. Should an isolated incident of this occur, we would certainly encourage that individual to be reported to the proper supervising authority. Athletic trainers have consistently been recognized by athletic governing bodies, medical societies and government legislatures for their positive and effective leadership role as it relates to concussion management.
    In order to provide context, the full NWSL concussion policy should have been disclosed as well as the fact that it is nearly identical as that of US Soccer and Major League Soccer. Similar to the NFL concussion policy, all are based on international concussion consensus statements derived on the latest research and experience of the leading global authorities in the field of concussion. The article fails to mention the full gradual progression of physical activity, incorrectly implies that the only requirement for return to play is that player must head a ball 45 times over three days and pass impact. It falsely states (athletic) trainers arbitrarily decide that imPACT testing will occur one week after a fail. As more research becomes available, it can be expected that policies will adapt and improve. Perhaps the mentioned heading component will change. Certainly if there are flaws to be addressed or ways to improve policy, they should be encouraged.
    In some cases, the occurrence of head impact and/or the presence of symptoms requiring a concussion evaluation is obvious and that player should be removed from competition by the referee, coach, physician, or athletic trainer immediately as most, if not all, concussion policies require. We agree that the preponderance of concussion diagnosis is based on self-reporting by athletes about the head contact itself, how they feel, or the development of symptoms. However, this is the current primary basis for concussion diagnosis across all sports and leagues including NWSL and NFL, independent of the individual performing the exam whether it be the team athletic trainer, team physician or independent medical consultant. We are eagerly awaiting a validated sideline tool that clearly and immediately diagnosis a concussion whether it be eye-tracking device, salivary test, digital balance or other emerging technology. Player reporting behaviors have long been known to be an challenge in concussion diagnosis. That is the basis behind significant amounts of research funding being devoted to the social behaviors and concussion reporting (see NCAA/Dept. of Defense Mind Matters project).
    Research has demonstrated that those (I.E. athletic trainers) who know the player and their “normal” behavior patterns and mannerisms are more accurate and likely to detect concussions than those with no previous relationship with the player. Players are more likely to be honest in regards to their symptoms with someone that they have a personal relationship such as the athletic trainer. Emerging research demonstrates that female athletes are more likely to self-report concussion symptoms, which is one of the multiple proposed reasons that the female concussion rate is reportedly higher than their male counterparts. It is important to note the evaluation the player undergoes with the independent neurologist is very similar or identical to that of the team’s athletic trainer or physician
    The article specifically cites the role of the spotter and unaffiliated medical provider as it relates to the NFL’s concussion policy. It inappropriately quotes, without a citation or context, an 11.3% drop in concussions. Statistically, the spotter and independent neurologist would actually lead to higher levels of detection of potential concussive events, increasing the number of evaluations therefore elevating the concussion rate. The drop of 11.3% has been attributed to other important factors including rule changes reducing the number of kickoff returns and enforcement of targeting the head penalties. We encourage the governing bodies of soccer to continuing to look at rule changes and/or enforcement of current rules to decrease the incidence of concussion.
    One complicating factor is that the substitution rules are different between the NFL and professional soccer. Transferring a system from one sport to another needs to occur via a deliberate method. For example, the NFL has used instant replay for years and as we have witnessed in the recent Confederations Cup implementation of the Video Assistant Referee (VAR) system will take some time before it is fully functional in the sport of soccer. It is important to note, there are on-going trials of both spotters and independent neurologist at both the MLS and NCAA soccer levels to determine feasibility and effectiveness. If shown to be of value, one can expect that it will be adopted by NWSL, NCAA, MLS, and other sports.
    Again, SATS encourages all efforts to improve concussion care for players. We would gladly engage and provide assistance as it relates to any matter focused on improving soccer player medical care.

  • Soccer AT Society

    The Soccer Athletic Trainers’ Society (SATS) has been made aware of a recent article published by Rachel Breton in Excelle Sports titled “Pro players speak out about the ‘absurdity’ of the concussion protocol in women’s soccer” by concerned members. We applaud Ms. Breton’s efforts to push forth the conversation about concussions and the care that players receive. She makes a few valid points however, there are several statements made about athletic trainers that we feel must be addressed.
    Foremost, we have a significant concern about the statement: “(Athletic) trainers often advise players not to report concussion symptoms so they can continue to be used in match play.” We feel this to be dangerous, inflammatory and unfounded. This false implication that there is broad malfeasance by athletic trainers as well as team physicians erodes public trust in those that have been tasked and held responsible with ensuring player safety. We are not aware of any specific cases or any research that supports this statement in any fashion. Should an isolated incident of this occur, we would certainly encourage that individual to be reported to the proper supervising authority. Athletic trainers have consistently been recognized by athletic governing bodies, medical societies and government legislatures for their positive and effective leadership role as it relates to concussion management.
    In order to provide context, the full NWSL concussion policy should have been disclosed as well as the fact that it is nearly identical as that of US Soccer and Major League Soccer. Similar to the NFL concussion policy, all are based on international concussion consensus statements derived on the latest research and experience of the leading global authorities in the field of concussion. The article fails to mention the full gradual progression of physical activity, incorrectly implies that the only requirement for return to play is that player must head a ball 45 times over three days and pass impact. It falsely states (athletic) trainers arbitrarily decide that imPACT testing will occur one week after a fail. As more research becomes available, it can be expected that policies will adapt and improve. Perhaps the mentioned heading component will change. Certainly if there are flaws to be addressed or ways to improve policy, they should be encouraged.
    In some cases, the occurrence of head impact and/or the presence of symptoms requiring a concussion evaluation is obvious and that player should be removed from competition by the referee, coach, physician, or athletic trainer immediately as most, if not all, concussion policies require. We agree that the preponderance of concussion diagnosis is based on self-reporting by athletes about the head contact itself, how they feel, or the development of symptoms. However, this is the current primary basis for concussion diagnosis across all sports and leagues including NWSL and NFL, independent of the individual performing the exam whether it be the team athletic trainer, team physician or independent medical consultant. We are eagerly awaiting a validated sideline tool that clearly and immediately diagnosis a concussion whether it be eye-tracking device, salivary test, digital balance or other emerging technology. Player reporting behaviors have long been known to be an challenge in concussion diagnosis. That is the basis behind significant amounts of research funding being devoted to the social behaviors and concussion reporting (see NCAA/Dept. of Defense Mind Matters project).
    Research has demonstrated that those (I.E. athletic trainers) who know the player and their “normal” behavior patterns and mannerisms are more accurate and likely to detect concussions than those with no previous relationship with the player. Players are more likely to be honest in regards to their symptoms with someone that they have a personal relationship such as the athletic trainer. Emerging research demonstrates that female athletes are more likely to self-report concussion symptoms, which is one of the multiple proposed reasons that the female concussion rate is reportedly higher than their male counterparts. It is important to note the evaluation the player undergoes with the independent neurologist is very similar or identical to that of the team’s athletic trainer or physician
    The article specifically cites the role of the spotter and unaffiliated medical provider as it relates to the NFL’s concussion policy. It inappropriately quotes, without a citation or context, an 11.3% drop in concussions. Statistically, the spotter and independent neurologist would actually lead to higher levels of detection of potential concussive events, increasing the number of evaluations therefore elevating the concussion rate. The drop of 11.3% has been attributed to other important factors including rule changes reducing the number of kickoff returns and enforcement of targeting the head penalties. We encourage the governing bodies of soccer to continuing to look at rule changes and/or enforcement of current rules to decrease the incidence of concussion.
    One complicating factor is that the substitution rules are different between the NFL and professional soccer. Transferring a system from one sport to another needs to occur via a deliberate method. For example, the NFL has used instant replay for years and as we have witnessed in the recent Confederations Cup implementation of the Video Assistant Referee (VAR) system will take some time before it is fully functional in the sport of soccer. It is important to note, there are on-going trials of both spotters and independent neurologist at both the MLS and NCAA soccer levels to determine feasibility and effectiveness. If shown to be of value, one can expect that it will be adopted by NWSL, NCAA, MLS, and other sports.
    Again, SATS encourages all efforts to improve concussion care for players. We would gladly engage and provide assistance as it relates to any matter focused on improving soccer player medical care.

  • Soccer AT Society

    The Soccer Athletic Trainers’ Society (SATS) has been made aware of a recent article published by Rachel Breton in Excelle Sports titled “Pro players speak out about the ‘absurdity’ of the concussion protocol in women’s soccer” by concerned members. We applaud Ms. Breton’s efforts to push forth the conversation about concussions and the care that players receive. She makes a few valid points however, there are several statements made about athletic trainers that we feel must be addressed.
    Foremost, we have a significant concern about the statement: “(Athletic) trainers often advise players not to report concussion symptoms so they can continue to be used in match play.” We feel this to be dangerous, inflammatory and unfounded. This false implication that there is broad malfeasance by athletic trainers as well as team physicians erodes public trust in those that have been tasked and held responsible with ensuring player safety. We are not aware of any specific cases or any research that supports this statement in any fashion. Should an isolated incident of this occur, we would certainly encourage that individual to be reported to the proper supervising authority. Athletic trainers have consistently been recognized by athletic governing bodies, medical societies and government legislatures for their positive and effective leadership role as it relates to concussion management.
    In order to provide context, the full NWSL concussion policy should have been disclosed as well as the fact that it is nearly identical as that of US Soccer and Major League Soccer. Similar to the NFL concussion policy, all are based on international concussion consensus statements derived on the latest research and experience of the leading global authorities in the field of concussion. The article fails to mention the full gradual progression of physical activity, incorrectly implies that the only requirement for return to play is that player must head a ball 45 times over three days and pass impact. It falsely states (athletic) trainers arbitrarily decide that imPACT testing will occur one week after a fail. As more research becomes available, it can be expected that policies will adapt and improve. Perhaps the mentioned heading component will change. Certainly if there are flaws to be addressed or ways to improve policy, they should be encouraged.
    In some cases, the occurrence of head impact and/or the presence of symptoms requiring a concussion evaluation is obvious and that player should be removed from competition by the referee, coach, physician, or athletic trainer immediately as most, if not all, concussion policies require. We agree that the preponderance of concussion diagnosis is based on self-reporting by athletes about the head contact itself, how they feel, or the development of symptoms. However, this is the current primary basis for concussion diagnosis across all sports and leagues including NWSL and NFL, independent of the individual performing the exam whether it be the team athletic trainer, team physician or independent medical consultant. We are eagerly awaiting a validated sideline tool that clearly and immediately diagnosis a concussion whether it be eye-tracking device, salivary test, digital balance or other emerging technology. Player reporting behaviors have long been known to be an challenge in concussion diagnosis. That is the basis behind significant amounts of research funding being devoted to the social behaviors and concussion reporting (see NCAA/Dept. of Defense Mind Matters project).
    Research has demonstrated that those (I.E. athletic trainers) who know the player and their “normal” behavior patterns and mannerisms are more accurate and likely to detect concussions than those with no previous relationship with the player. Players are more likely to be honest in regards to their symptoms with someone that they have a personal relationship such as the athletic trainer. Emerging research demonstrates that female athletes are more likely to self-report concussion symptoms, which is one of the multiple proposed reasons that the female concussion rate is reportedly higher than their male counterparts. It is important to note the evaluation the player undergoes with the independent neurologist is very similar or identical to that of the team’s athletic trainer or physician
    The article specifically cites the role of the spotter and unaffiliated medical provider as it relates to the NFL’s concussion policy. It inappropriately quotes, without a citation or context, an 11.3% drop in concussions. Statistically, the spotter and independent neurologist would actually lead to higher levels of detection of potential concussive events, increasing the number of evaluations therefore elevating the concussion rate. The drop of 11.3% has been attributed to other important factors including rule changes reducing the number of kickoff returns and enforcement of targeting the head penalties. We encourage the governing bodies of soccer to continuing to look at rule changes and/or enforcement of current rules to decrease the incidence of concussion.
    One complicating factor is that the substitution rules are different between the NFL and professional soccer. Transferring a system from one sport to another needs to occur via a deliberate method. For example, the NFL has used instant replay for years and as we have witnessed in the recent Confederations Cup implementation of the Video Assistant Referee (VAR) system will take some time before it is fully functional in the sport of soccer. It is important to note, there are on-going trials of both spotters and independent neurologist at both the MLS and NCAA soccer levels to determine feasibility and effectiveness. If shown to be of value, one can expect that it will be adopted by NWSL, NCAA, MLS, and other sports.
    Again, SATS encourages all efforts to improve concussion care for players. We would gladly engage and provide assistance as it relates to any matter focused on improving soccer player medical care.

    • Soccer AT Society

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