Sports Medicine Research: In the Lab & In the Field: If You Don't Let Your Head Heal Your Knee May be Next (Sports Med Res)
Wednesday, August 27, 2014

If You Don't Let Your Head Heal Your Knee May be Next

Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players

Nordström A, Nordström P and Ekstran J. Br J Sports Med. 2013 [Epub Ahead of Print].

Take Home Message: After a concussion, elite level European football players have an elevated risk of injury for at least 1 year following a concussion.

Some athletes have mild cognitive impairments after they return to play following a concussion. Whether or not these impairments place an athlete at an increased risk of a subsequent injury is not understood. Therefore, Nordström and colleagues completed a prospective cohort study to “examine the risk of subsequent injury after return to play in football [soccer] players who had sustained concussions.” Researchers tracked players from 46 senior professional male football teams in 10 Europeans countries from July 2001 to June 2012. Each team registered injures that prevented a player from fully participating in training or matches. All players were considered “injured” until they were allowed to return to full participation with no limitations. Over the course of the observation period, 8,695 injuries, including 71 concussions were reported. Players with and without a concussion had similar age, weight, and height. Players who sustained a concussion, were more likely to sustain another injury when compared with athletes who did not experience a concussion. Interestingly, this was true even before the concussion. In fact, players with a concussion suffered on average 1.8 injuries in the year before a concussion compared with only 0.9 injuries among those with any other randomly selected injury. Furthermore, athletes who were concussed had a progressively increasing risk of sustaining another injury as time progressed. The players were most at risk 6-12 months after a concussion – the latest time frame that the researchers assessed. During this period the players were more than 4 times as likely to suffer another injury compared with players after any other type of injury. This was true even after the researchers accounted for the number of injuries that a player sustained during the year prior to a concussion or other type of injury.

The results of this study suggest that elite European football players with a concussion were at an increased risk of injury both the year before and after a concussion. This may indicate that the player’s position or playing style exposes them to a greater risk of injury (concussions included). Interestingly, players with a concussion were at greater risk for a new injury after their concussion even after the researchers accounted for the number of injuries the player sustained prior to the concussion. This should be of interest to clinicians, especially those who are directly involved in the decision to return a player to activity or those involved in addressing cognitive impairment after a concussion. Throughout the decision making process, clinicians need to be keenly aware that even after an athlete has satisfied all the return to play criteria, some cognitive impairment may exists. Further, it would also be in the interest of clinicians to better understand these impairment and how to better address them immediately after a concussion. These cognitive impairments may contribute to the greater risk of subsequent injuries; but, this will require further evidence to verify. While it is good to understand that a relationship may exist, clinicians should also be aware of the limitations of this study. Firstly, the players’ teams reported the injuries, which may introduce a reporting bias. Furthermore, by including only elite level football players it is unclear if these results can be applied to other levels of soccer (e.g., high school). Until more research can be completed on a more general population with more standardization, clinicians should continue to be cautious in their return to play decision making, and when necessary consult with other members of their sports medicine team to ensure that little or no cognitive impairment remain.

Questions for Discussion: Why do you think athletes are most at risk for a new injury 6 to 12 months after a concussion? After athletes return to play from a concussion, what, if any, screening do you continually perform to gauge their risk of injury?

Written by: Kyle Harris
Reviewed by:  Jeffrey Driban

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Nordstrom, A., Nordstrom, P., & Ekstrand, J. (2014). Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players British Journal of Sports Medicine DOI: 10.1136/bjsports-2013-093406

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