Concussions in soccer are becoming more evident, as seen in the World Cup final. Germany's Christoph Kramer was injured in a shoulder-to-head collision during the first half. He appeared concussed to the average viewer. Kramer even told the German newspaper Die Walt, "I can't really remember much of the game."

Germany’s medical staff evaluated Kramer on the sideline and returned him to the match. Approximately 15 minutes, later Kramer fell down on the field and was subsequently substituted.

FIFA's concussion management protocol is based on Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport, which is the gold standard for concussion management. The SCAT 3 and pocket SCAT 2 are the concussion tools used to evaluate athletes suspected of having a concussion. According to the consensus statement, if it is determined that the athlete has suffered a concussion, he is immediately removed from the game and may not play for a minimum of one week.

Did Kramer pass his sideline testing? Was the German staff not competent in assessing his concussion? Did they return him to play despite having a concussion?

From my observation, he had some obvious signs that would have raised serious concerns about a concussion. We will never know what truly occurred on the sideline, and these situations are becoming more common as seen in this World Cup like Gonzalo Higuaín in the final match, Javier Mascherano in the semi-finals and Álvaro Pereira in the group stages.

In any American sport, Kramer would have been removed from the game and a thorough concussion assessment would have been performed. The NFL even has independent concussion evaluators on each sideline to limit any bias from the team physician.

International soccer is behind American sports in the assessment and management of concussion. One problem is that they don't take them as seriously as we do here in the U.S.

Having to play down a man during the evaluation and the limited number of subs is another big problem for concussion assessment and management in international soccer. If the quick sideline test – as performed in the U.S. – shows signs of a possible concussion, a more formal evaluation can take upwards of 10-15 minutes to perform, which means the team will have to play down a man until it's completed.

Another issue is who is doing the assessment.  As we've seen, the team physicians have been very liberal about letting a player return. There is talk in soccer circles about having an independent physician on the sidelines that has the final say, much like the NFL. Another option may be to allow a temporary sub until the concussion evaluation is completed.

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