Villas Boas’ big concussion mistake and how it can be prevented in the future

Tottenham Hotspur goalkeeper Hugo Lloris lies unconscious after colliding with Everton’s Romelu Lukaku.

By now pretty much everyone following the football news cycle knows about the Hugo Lloris situation at Tottenham.

In Spurs’ 0-0 draw with Everton two weekends ago, the team decided to allow goalkeeper Hugo Lloris to continue playing after a collision with Romelu Lukaku had rendered him unconscious for a brief period. Lloris initially looked unable to continue and was set to go off on a stretcher, but after a lengthy delay the stretcher left the field empty and Lloris was allowed to play on.

Spurs manager Andre Villas-Boas was quick to defend the decision during his post-match media appearances. “It was a big knock, but he looked composed and ready to continue,” said the Tottenham boss. “Hugo seemed assertive and determined to continue and showed great character and personality. We decided to keep him on based on that. The call always belongs to me.”

Wayne Diesel, Tottenham’s head of medical services, also defended the team’s actions in returning Lloris to the field: “Once the relevant tests and assessments were carried out, we were totally satisfied that he was fit to continue playing.”

AVB shows himself up

Andre Villas Boas: “”Hugo seemed assertive and determined to continue and showed great character and personality. We decided to keep him on based on that. The call always belongs to me.”

Villas-Boas has not handled this situation very well. His comments and justifications for the club’s decision revolved around the fact that Lloris wanted to continue. He specifically mentioned that Lloris “seemed determined to continue and showed great character”, praising his goalkeeper’s determination to carry on playing and insinuating that it was a significant factor in allowing him to return to the game.

If that is true, it is a terrible piece of managing by Villas-Boas. A competitive sportsman always wants to continue playing. I have personal experience of it myself; I was knocked out cold in an American Football game and spent the rest of the game trying to convince my coach to let me go back in.

Players are not rational, and in the heat of competition they rarely think about their own safety first. Luke Griggs, the spokesman for brain-injury charity ‘Headway’, noted in his assessment of the incident that “Mr Villas-Boas’s comment that his player’s determination to play on was proof of his ‘great character and personality’ is simply wrong and dangerous.”

The decision could have been made primarily because of the medical assessments made by Tottenham’s medical staff, or it could have been influenced by the player’s own opinions. We will probably never know either way. Regardless, Villas-Boas conduct after the decision was made has been nothing short of ridiculous.

The most infuriating aspect of this entire situation was not the manager’s original decision to keep Lloris on the field, but his outrageous insistence throughout that he did the right thing. Villas Boas maintained that he made the correct decision, saying “I stand absolutely by the decision I took and I stand by the decision that the medical department took following the checks that they made on the player.”

The Spurs’ manager said this on 6^th November. The very next day he left the goalkeeper out of his side for the team’s Europa League clash with Sheriff on the advice of his medical team. Three days later in their EPL clash with Newcastle United, Lloris was left out again.

Keeping Lloris out of the starting eleven would indicate to any reasonable man that Villas-Boas did indeed make the wrong decision by leaving his goalkeeper on the pitch at Goodison Park. Lloris clearly was not well in the week following his head injury; so much so that he wasn’t able to play in a game 7 days after the initial incident took place. As Gary Linekar pointed out, that is itself an admission of a mistake:

So what Villas-Boas is effectively saying by a combination of his defensive words and his revealing team selections is “we made a mistake in letting Lloris play for the rest of the Everton game because he has not been fit enough to play in the two games following his head injury. However, I absolutely stand by the decision I made and I stand by my medical department’s assessment of Lloris even though it was obviously wrong and potentially dangerous to let him continue playing.”

What makes Villas-Boas look even more foolish is that he is defending his decision in the wake of a battering of criticism from much more qualified sources. He is, in essence, defending a medical decision against doctors.

World players’ union FIFPro, the Professional Footballers’ Association and numerous brain charities were among those critical of Villas-Boas. FIFPro medical advisor Vincent Gouttebarge said that “the decision is unacceptable”. FIFA’s chief medical officer, Professor Jiri Dvorak, felt Lloris should have been substituted in accordance with the governing body’s guidelines. He said that “It’s a 99% probability that losing consciousness in such an event will result in concussion. We have a slogan: if there is any doubt, keep the player out.”

Professor Jiri Dvorak, FIFA’s chief medical officer: “if there is any doubt, keep the player out.”

Luke Griggs of ‘Headway’ also felt Spurs made the wrong call:

“When a player suffers a blow to the head that is severe enough for them to lose consciousness, it is vital they urgently seek appropriate medical attention. A physio or doctor treating a player on the pitch simply cannot accurately gauge the severity of the damage caused to the player’s brain in such a setting as there may be delayed presentation of symptoms. By continuing to play, the player may have caused greater damage to his brain. He should have been removed from the game immediately and taken to hospital for thorough tests and observation.”

Why would you defend your mistakes when it is so obvious to everyone that you got it completely and utterly wrong? By sticking to his guns, Villas-Boas has come out of this entire saga looking like the kid in the playground with chocolate around his mouth, vigorously denying that he stole your Mars bar. It’s not a good look for a man who is supposed to be in charge of an entire football team.

The important aspect of this story, however, is not Villas-Boas’ supposed incompetence. It is that the footballing world hears the voices of the experts concerned, and doesn’t let this happen again. The football authorities can learn from this entire incident and use that knowledge to become more adept at preventing future head trauma controversies.

Preventing future occurrences

Villas Boas clearly believes that the Spurs’ staff did not do anything wrong when handling the Lloris situation. According to him, they made the necessary concussion assessment and deemed the goalkeeper fit to continue. He said specifically that “All the checks were according to the book.” If that is true, and there isn’t really any reason to believe that it is not true, then there is only one thing the Football Association can do.

Change the book.

The ‘book’ currently allows for a player to continue playing if he is assessed and cleared to play by a doctor. But what can be ascertained from these events is that side line assessments are not a fool proof system of properly ensuring the safety of players after a head injury, and certainly not by the team’s own medical staff.

So it seems that in the interests of safeguarding the players on the field, something needs to change before a serious injury occurs.

To do that, it might be prudent to look at what other sports are doing with regard to instances of suspected concussions. Football, after all, is not a familiar battle ground for the head-trauma health and safety warriors.

After a plethora of concussion-related injuries in the National Football League (NFL) led to a law suit against the league by families of ex-players, the NFL Players Association instigated strictly enforced concussion rules to help prevent future problems. This was namely the introduction of ‘Unaffiliated Neuro-trauma Consultants’ for the 2013 season. The concussion experts, who are not paid by the teams, will make the determination of whether a player should be taken to the locker room for the X2 Bio concussion test.

However, even side line concussion assessments such as this have been criticised. Former medical adviser to the International Rugby Board (IRB), Dr Barry O’Driscoll, was so opposed to the IRB’s instigation of the five minute ‘Pitchside Suspected Concussion Assessment’ (PSCA) that he reluctantly resigned his post after 15 years of service to the IRB.

In a letter that O’Driscoll wrote to the IRB to highlight his concerns, RTE Sport reported that the Doctor stated “The five-minute assessment of a player who has demonstrated distinct signs of concussion for 60 to 90 seconds and usually longer, is totally discredited.” The Doctor also told ‘The Scotsman’ that “There is no test that you can do in five minutes that will show that a player is not concussed.”

Dr Barry O’Driscoll, former medical adviser to the IRB, resigned his post because of concerns regarding the treatment of concussions in the sport.

FIFPro and the PFA have adopted Dr O’Driscoll’s cautionary approach to the issue. They are calling for players who lose consciousness to be forced to leave the field, whether they show symptoms of concussion or not. The idea has some merit; a player who loses consciousness is highly likely to suffer a concussion after the event. Professor Dvorak said as much when he commented on the matter. Perhaps the best way to approach brain injuries is to err on the side of caution and adhere to something else that Professor Dvorak stated “if there is any doubt, keep the player out”.

As for head injuries that do not result in a loss of consciousness, the NFL’s principle of ensuring that neutral, expert medical professionals are on hand at games to assess head injuries seems to be a workable idea. The EPL could certainly afford to supply one medical expert to each premier league match, and they would make their own assessments as to the player’s ability to continue.

Keeping with that theme, Northants Telegraph reporter Huw Silk came up with an inspired solution to sell this idea to teams and managers in the EPL. He worked on the notion that managers would be reluctant to ‘waste’ a substitution on a vague head injury, and so suggested that a player with a head injury, as defined by an independent doctor at each EPL game, would not count as one of the team’s three substitutions.

A combination of those ideas would certainly prevent any future instances of controversy. It would keep players safe, and would likely be an acceptable solution to every interested party from EPL managers to brain-injury charities. Let’s just hope that the English FA is as smart as Mr Silk.

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Lloris rested once more, an admission in itself that Spurs erred in leaving him on last week.

— Gary Lineker (@GaryLineker) November 10, 2013

Hugo Lloris: how about not counting a substitution for concussion as one of the 3 permitted? In those circs AVB would’ve taken Lloris off

— Huw Silk (@huwsilk) November 4, 2013