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].

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