Christoph Kramer does not recall much about the 2014 World Cup Final.
There’s nothing particularly unusual about that. It was hardly a classic and Germany won (again). Except for the fact the midfielder lifted the trophy after playing against Argentina at the Maracana that day.
Kramer’s memories of the final are a little foggy, but his experience was the spark for a campaign that will see football finally catch up with the rest of global sport in terms of how to handle concussions.
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On October 23, the game’s law-making body the International Football Association Board (IFAB) will hold a series of advisory panel meetings in Zurich.
Top of the agenda is a proposal to increase the current three-minute assessment window for a suspected concussion, which is granted at a referee’s discretion, to a mandatory 10-minute test.
This would take place off the field of play, in line with best practice elsewhere — most notably in the NFL and both codes of rugby — and would therefore require a temporary ‘concussion substitute’.
It is expected that IFAB will appoint a ‘task force’ to come up with answers to questions about who should do this assessment and how quickly an injured player should be allowed to resume training. It is hoped a protocol can be drafted in time for IFAB’s annual business meeting in December.
That is when a formal recommendation to change the game’s laws can be made, but an actual change can only be approved at an IFAB AGM, with the next one in early March in Scotland.
The Athletic has spoken to several sources who say a change is inevitable and overdue, with the only unresolved issues being secondary concerns about what happens if the temporary substitute gets injured or if they should count as one of the team’s three allowed changes.
To explain why it has taken so long to reach this point, we should return to Kramer because the then 23-year-old’s World Cup is best remembered for his question to referee Nicola Rizzoli: “Is this the final?”
It came after he had collided with Argentina defender Ezequiel Garay in the 17th minute but been cleared to carry on by Germany’s medical staff.
Confused by the question, Rizzoli asked the midfielder, who was only playing because Sami Khedira got injured in the warm-up, to repeat it. Dazed, Kramer did.
Realising this was not the type of thing a footballer usually forgets, Rizzoli alerted Germany’s captain Bastian Schweinsteiger and Kramer was replaced by Andre Schurrle in the 31st minute.
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Watching at home was Dr Vincent Gouttebarge, chief medical officer at the global players’ union FIFPRO. He did not like what he was seeing because he knew just how dangerous those 14 minutes between collision and substitution could be for a footballer.
Once a promising defender with Auxerre, Gouttebarge’s own playing career was compromised by injuries, including two concussions while playing in the Netherlands in 1998 and 2003. On both occasions, he was allowed to play on by club doctors only to be substituted later when team-mates realised he was disorientated.
The initial misdiagnosis of Kramer’s injury had come only three weeks after a similar incident at the World Cup in Brazil involving Uruguay’s Alvaro Pereira in the group-stage match against England. The defender was accidentally knocked out by Raheem Sterling’s knee but then allowed to play on after two minutes of treatment. He later admitted the “lights had gone out”.
“The lights had gone out”: Pereira receives medical treatment after colliding with Raheem Sterling at the 2014 FIFA World Cup (Photo: JUAN BARRETO/AFP/Getty Images)
Then Argentina’s Javier Mascherano collapsed on the pitch following a clash of heads with Dutch midfielder Gini Wijnaldum during their semi-final. He too was allowed to play on.
The risks to Kramer, Mascherano and Pereira were clear: injured brains are much more vulnerable to further injury, with serious implications for recovery.
These incidents took place on football’s biggest stage, but there had been several other cases involving high-profile players in important games.
Gouttebarge and FIFPRO had seen enough and started to urge world football’s governing body FIFA to look at what was happening elsewhere and come up with a coherent, safety-first approach to concussion.
UEFA was the first to respond. It introduced the three-minute assessment in time for the start of the 2014-15 season. To be fair to European football’s governing body, it has continued to push the argument.
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Speaking after an executive committee meeting in Baku in May, UEFA president Aleksander Ceferin said: “I strongly believe the current regulations on concussion need updating to protect both the players and the doctors and to ensure appropriate diagnosis can be made without disadvantaging the teams affected.”
FIFA’s executive committee discussed a similar policy five years ago, too. The prevailing view then was football is not boxing and it would hurt the game’s ‘universality’ if a change was made at the elite end that could not easily be replicated in grassroots football. There was also thought to be a risk of teams gaming the system to waste time or gain an extra substitute.
Ross Tucker is a South African sports scientist who was brought in by World Rugby as a consultant to help change its approach to head injuries. He remembers hearing these concerns.
“FIFA’s resistance to mandatory concussion assessments and temporary substitutes has always been a bit baffling,” Tucker told The Athletic. “Sure, the incidence of concussion is low in football but the relatively rare events they have stand out all the more as a result.
“I remember at two conferences I attended, senior FIFA medical staff rejected the idea of temporary substitutions because they were so worried teams would cheat for a tactical advantage.”
Tucker has also never been convinced by the ‘universality’ argument. Sunday league teams are not using VAR or goal-line technology, after all. In amateur rugby the concussion protocol is simple: “Recognise and remove (from the field) — end of.”
He does, however, have more time for the arguments he has heard within football and rugby about why it is better to let team doctors, who really know the player, conduct the concussion assessment, as opposed to an independent doctor.
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The argument for the latter is that a team doctor could be swayed by the manager or coaching staff, whereas an independent physician would be under no pressure to get a key player back on the field.
Tucker says the evidence from rugby suggests doctors who are familiar with a player give better assessments and the key bit is that the test is done off the field.
“Once the player is off, it’s a lot easier to keep them off, and the simple act of making a sub, and having some time, is likely to prevent a concussed player from staying on,” he explained.
“Five minutes is too short. You can’t assess enough different functions — it’s too rushed, too superficial. Fifteen minutes is too long. There would be an issue with tactical subs, resting players, getting another sub and so on. So 10 minutes does it.”
Gouttebarge agrees on the time needed but would still like some independent oversight.
“FIFPRO has campaigned for an improved concussion protocol in football since 2014 and we welcome the growing momentum among other stakeholders in the game to pursue better safety measures,” he said.
“New rules should be defined to provide medical staff with at least 10 minutes to assess a potentially concussed player, and independent doctors should be on hand to help make the correct diagnosis.
“It is equally important to introduce rules that ensure concussed players do not return to play until they are fully recovered, at least six days after they are injured.
“We look forward to working with IFAB to bring football in line with other sports that have more rigorous concussion protocols, both during and after matches.
“The long-term underlying effects of concussion on footballers remain little-known and we remain committed to working with our research partners in this area.”
On that last point, he is undoubtedly right and football’s bosses have finally realised it, too.
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As self-styled custodian of the game’s laws, IFAB once took its conservatism very seriously, rarely bowing to pressure to simply ‘do something’ when doing nothing was probably fine.
But the trickle of sad stories about former players suffering with dementia or other brain-related illnesses has become a flood in recent years, starting with Jeff Astle, who died from what the coroner described as an ‘industrial disease’. Several players from England’s World Cup winning team of 1966 have suffered too.
Whether that is truly linked to football, or just a by-product of longer lifespans and football’s high profile, is the subject of the various research projects referred to by Gouttebarge.
Hopefully, Kramer and co did not suffer any long-term damage from the blows they took in Brazil, but a contact sport as popular and wealthy as football can no longer ignore the very strong hints emerging from that research.
(Top photo: Matthias Hangst/Getty Images)
Based in North West England, Matt Slater is a senior football news reporter for The Athletic UK. Before that, he spent 16 years with the BBC and then three years as chief sports reporter for the UK/Ireland's main news agency, PA. Follow Matt on Twitter @mjshrimper
