Head in the Game: Concussions in the NWSL


The NWSL doesn’t do everything right. Being a newer league, it has limited funding in comparison to other sports and its business structure still needs a lot of fine tuning. They are learning, and growing, and making fantastic strides forward, but it would be unreasonable to expect the NWSL to be best-in-class in the sporting world.

Last Saturday, the NWSL and the Orlando Pride faced a decision when Alex Morgan collided with Abby Smith in the 45th minute. Given what happened, they did the best that any league or club could do. 

The knock to Morgan’s head was hard. Anyone in the stadium or watching at home could see it. She stayed down and the training staff immediately went to assess the potential head injury. After a few minutes she was taken to the locker room and then it was decided that she would not play the remaining of the game after being evaluated under a complete concussion protocol.

That was the most important call of the game. By far. And it’s an important precedent for not only this league but for sports in general.

Concussions are serious injuries that haven’t always been taken seriously. It is only lately that the long-term effects of head injuries—and the impact that contact sports plays on the brain—have come to light. For some sports, such as football and boxing, head injuries are finally becoming a major consideration when it comes to whether an athlete is allowed to compete, or how long he or she must sit out.

But they don’t always get it right. Money, league politics, and pending legal matters have all been factors in the debate of proper concussion protocol throughout all of sports. It’s inevitable, because professional sport is such a profitable business. Things are getting better, and awareness is being raised, but things are still far from perfect.

One example: in the discussion around head injuries, very little attention has thus far been paid to female athletes.  The focus generally seems to gear towards football, but according to the American Academy of Orthopedic Surgeons, female soccer players suffer the highest rate of concussions in high school sports. Moreover, in gender-matched sports, girls experienced significantly higher concussion rates than boys. A consensus study by the NCAA from 2015 revealed that concussions are the second-most common injury in women’s soccer.

The numbers are staggering, and the long-term effects of these traumatic brain injuries (TBI) will only cause greater issues for players down the road. Years after a concussion, there can still be abnormal brain wave activity, which can lead to the deterioration of motor pathways and attention problems. In extreme cases, it can lead to Parkinson’s-like symptoms, or as a UCLA study found, manifest the tau proteins that are linked with Alzheimer’s. Repeated concussions could also force surgery on the occipital nerves in the neck to help alleviate some of the symptoms. Sadly, for Manya Makoski, a former NWSL midfielder, this was a reality

So the threat is real and the league needs to come up with a game plan for how to handle it. It currently follows the US Soccer Concussion Guidelines, which centers a lot on education and initiatives to bring awareness and promote safety. One of those initiatives is Recognize to Recover. This standard looks to train the athletes, coaches, and training staff on how to look for signs of possible head injuries, and steps on how to recover. That is a great start. And the example cited above—with Morgan being removed from the game due to risk of concussion—shows they’re taking the issues seriously. But just because something works, doesn’t mean that it shouldn’t be improved upon. In fact, US Soccer and the NWSL have the opportunity to set the standard for concussion safety. They are on the right track, but there’s no such thing as being too far ahead of the curve on this point.

The current US Soccer Concussion Protocol starts at the the beginning of a player’s time at a US Soccer Development Academy. They receive a baseline test through the use of Standardized Concussion Assessment Tool 3 (SCAT3) and an ImPACT neurological test. This baseline is retested every two years unless a concussion is detected. Then, when a concussion is suspected, they go through a four-step testing over the course of numerous days depending on how their symptoms progress. If a player is still symptomatic, they will not progress to the next step until they have achieved the baseline level of symptoms for that time frame. This is a great start. But one issue is that the four-step testing involves heading the ball—something that could potentially cause more trauma if certain symptoms are missed, or unrecognizable. 

So what more can the league and US Soccer do to help ensure the players’ safety and long-term health?

First, they could modify their policy on identifying concussions. Part of the current concussion protocol is that players must report if they suspect that they have a possible concussion. If the collision does not happen in the game, or does not appear problematic in practice or training, then often times the training staff does not have the opportunity to diagnose the issue. But putting that responsibility on players can lead to a lot of undiagnosed concussions. Most professional athletes will do everything in their power to stay in the game, and are unlikely to fully grasp the long-term health risks. Giving them the power to control that decision point is a bad idea. Discretion should be in the hands of a neutral party, not the players themselves. 

That relates to a second change: hiring unaffiliated doctors. This is a reality for a lot of leagues, and for US Soccer. But for the NWSL, this is a much greater feat. It wouldn’t be feasible today, but down the road once the league has more stability and wealth, it should be a priority. Currently, training staffs and doctors are set on a club-by-club basis. Being employed by the club, they have a certain stake in the result of the game, a problem that wouldn’t exist for unaffiliated doctors who are there to collect data, establish safety protocols, and provide unbiased healthcare and strategy regardless of the team. Other leagues like the NFL use this model, with positive results on treatment and research.

Finally, not necessarily another change, but a different utilization of assets, could come in handy for US Soccer and the NWSL in the long term. Yesterday it was announced that US Soccer is partnering with STATSports as the official on-field monitoring device. These devices will be able to stream in real-time, providing vital information for benchmarking, injury prevention, and improved performance. The best part is that these monitors will be distributed through the development academies, the NWSL, and the national teams, while all the information is compiled centrally and can be cross-referenced. And although this tool was not purchased to help track and monitor concussions, the NWSL and US Soccer could use it to help with the research that surrounds them: how an athlete performs before and after a TBI, how that potential concussion could have effected motor function in the long term, or even find trends to help identify different long-term symptoms of a head injury.

The NWSL should strive to be a leader on this issue. Although concussions can affect any athlete, the research is unequivocal that female soccer players are particularly high-risk. This isn’t something people talk about much. But they should. And that fact puts the NWSL in a great position to set the standard across the board. They can be the league that takes care of their players. They can be the league that others look to for guidance. They can be the league that takes this issue seriously.

It shouldn’t take a potential concussion by the biggest name in the sport to get us talking, and to create action. But hopefully this becomes a catalyst for real concussion reform in the league, and the game itself. They did things right this weekend—Morgan was assessed correctly and was pulled from the match—but that shouldn’t lead to complacency. The good start means that the league can start off from a point of positivity. They’re already on the right path, and should strive to stay ahead of the ball on this issue, not be forced to address it after a major crisis. 

Make changes now to prevent sadness down the road. Be the standard for others to follow. This issue is big. The consequences are huge. And the players’ lives are invaluable. It’s not enough to just sit around and hope for the best as the athlete checks back into the match. In fact, that’s the least that can be done.

Image courtesy of Leanne Keator
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