Do Sports-related Concussions Induce Subsequent Injuries in Elite Male Football Players?

Abstract

To assess the players’ risk of a subsequent injury after sustaining concussive injuries and their return-to-competition in German professional men’s football. A prospective injury database in the 1^st Bundesliga was created encompassing 7 seasons (2014/15–2020/21). Cox proportional hazard model analyzed whether a concussive injury increased the risk of a subsequent injury in the first year after the index injury. 6,651 injuries were reported (n=182 concussive injuries). The incidence rate was 0.15 (95% CI 0.13–0.17) per 1000 football hours. A concussive injury was associated with only a slightly numerical higher risk of 7% (HR=1.07, 95% CI 0.78–1.47) in the subsequent year after the injury compared to a randomly selected non-concussive injury, but the effect was not significant. The risk was higher after 6–12 months post-SRC reaching 70% (HR=1.70, 95% CI 1.15–2.52). For 0–3 months (HR=0.76, 95% CI 0.48–1.20) and 3–6 months (HR=0.97, 95% CI 0.62–1.50) the injury risk was lower. The present data do not confirm previously published investigations about an increased injury risk after SRC. Contrasting effects of lower hazard ratios were found early after SRC, followed by an increase after 6–12 months. Further research should look into compliance rates with regards to return-to-competition protocols.

Key words

head injury - traumatic brain injury - soccer - prevention - sequalae

Publication History

Received: 28 March 2022

Accepted: 08 November 2022

Accepted Manuscript online:
08 November 2022

Article published online:
17 March 2023

• References

• 1 McCrory P, Meeuwisse W, Dvorak J. et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017; 51: 838-847 DOI: 10.1136/bjsports-2017-097699.
• 2 Beaudouin F, der Funten KA, Tross T. et al. Time trends of head injuries over multiple seasons in professional male football (soccer). Sports Med Int Open 2019; 3: E6-E11 DOI: 10.1055/a-0808-2551.
• 3 Harmon KG, Clugston JR, Dec K. et al. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med 2019; 53: 213-225 DOI: 10.1136/bjsports-2018-100338.
• 4 Howell DR, Lynall RC, Buckley TA. et al. Neuromuscular control deficits and the risk of subsequent injury after a concussion: A scoping review. Sports Med 2018; 48: 1097-1115 DOI: 10.1007/s40279-018-0871-y.
• 5 Nordstrom A, Nordstrom P, Ekstrand J. Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players. Br J Sports Med 2014; 48: 1447-1450 DOI: 10.1136/bjsports-2013-093406.
• 6 Herman DC, Jones D, Harrison A. et al. Concussion may increase the risk of subsequent lower extremity musculoskeletal injury in collegiate athletes. Sports Med 2017; 47: 1003-1010 DOI: 10.1007/s40279-016-0607-9.
• 7 Brooks MA, Peterson K, Biese K. et al. Concussion increases odds of sustaining a lower extremity musculoskeletal injury after return to play among collegiate athletes. Am J Sports Med 2016; 44: 742-747 DOI: 10.1177/0363546515622387.
• 8 Cross M, Kemp S, Smith A. et al. Professional Rugby Union players have a 60% greater risk of time loss injury after concussion: a 2-season prospective study of clinical outcomes. Br J Sports Med 2016; 50: 926-931 DOI: 10.1136/bjsports-2015-094982.
• 9 Lynall RC, Mauntel TC, Padua DA. et al. Acute lower extremity injury rates increase after concussion in college athletes. Med Sci Sports Exerc 2015; 47: 2487-2492 DOI: 10.1249/MSS.0000000000000716.
• 10 Lutz RH, DeMoss DJ, Roebuck EH. et al. Sport-specific increased risk of anterior cruciate ligament injury following a concussion in collegiate female lacrosse. Curr Sports Med Rep 2021; 20: 520-524 DOI: 10.1249/JSR.0000000000000839.
• 11 Mooney J, Self M, ReFaey K. et al. Concussion in soccer: a comprehensive review of the literature. Concussion 2020; 5: CNC76 DOI: 10.2217/cnc-2020-0004.
• 12 Beaudouin F, Aus der Funten K, Tross T. et al. Head injuries in professional male football (soccer) over 13 years: 29% lower incidence rates after a rule change (red card. Br J Sports Med 2019; 53: 948-952 DOI: 10.1136/bjsports-2016-097217.
• 13 Krutsch V, Grechenig S, Loose O. et al. Injury analysis in professional soccer by means of media reports – only severe injury types show high validity. Open Access J Sports Med 2020; 11: 123-131 DOI: 10.2147/OAJSM.S251081.
• 14 Harriss DJ, Jones C, MacSween A. Ethical standards in sport and exercise science research: 2022 update. Int J Sports Med 2022; 43: 1065-1070 DOI: 10.1055/a-1957-2356.
• 15 Donaldson L, Asbridge M, Cusimano MD. Bodychecking rules and concussion in elite hockey. PLoS One 2013; 8: e69122 DOI: 10.1371/journal.pone.0069122.
• 16 Fuller CW, Ekstrand J, Junge A. et al. Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. Br J Sports Med 2006; 40: 193-201 DOI: 10.1136/bjsm.2005.025270.
• 17 aus der Funten K, Faude O, Lensch J. et al. Injury characteristics in the German professional male soccer leagues after a shortened winter break. J Athl Train 2014; 49: 786-793 DOI: 10.4085/1062-6050-49.3.51.
• 18 Krutsch W, Memmel C, Krutsch V. et al. High return to competition rate following ACL injury – A 10-year media-based epidemiological injury study in men’s professional football. Eur J Sport Sci 2020; 20: 682-690 DOI: 10.1080/17461391.2019.1648557.
• 19 Hagglund M, Walden M, Ekstrand J. Injury recurrence is lower at the highest professional football level than at national and amateur levels: does sports medicine and sports physiotherapy deliver. Br J Sports Med 2016; 50: 751-758 DOI: 10.1136/bjsports-2015-095951.
• 20 Shenton ME, Hamoda HM, Schneiderman JS. et al. A review of magnetic resonance imaging and diffusion tensor imaging findings in mild traumatic brain injury. Brain Imaging Behav 2012; 6: 137-192 DOI: 10.1007/s11682-012-9156-5.
• 21 Ling JM, Klimaj S, Toulouse T. et al. A prospective study of gray matter abnormalities in mild traumatic brain injury. Neurology 2013; 81: 2121-2127 DOI: 10.1212/01.wnl.0000437302.36064.b1.
• 22 Bigler ED, Maxwell WL. Neuropathology of mild traumatic brain injury: relationship to neuroimaging findings. Brain Imaging Behav 2012; 6: 108-136 DOI: 10.1007/s11682-011-9145-0.
• 23 Palacios EM, Sala-Llonch R, Junque C. et al. Long-term declarative memory deficits in diffuse TBI: correlations with cortical thickness, white matter integrity and hippocampal volume. Cortex 2013; 49: 646-657 DOI: 10.1016/j.cortex.2012.02.011.
• 24 Makdissi M, McCrory P, Ugoni A. et al. A prospective study of postconcussive outcomes after return to play in Australian football. Am J Sports Med 2009; 37: 877-883 DOI: 10.1177/0363546508328118.
• 25 Nyberg G, Mossberg K, Lysholm J. et al. Subsequent traumatic injuries after a concussion in elite ice hockey : A study over 28 years. Curr Res Concussion 2015; 2: 109-112
• 26 Chmielewski TL, Tatman J, Suzuki S. et al. Impaired motor control after sport-related concussion could increase risk for musculoskeletal injury: Implications for clinical management and rehabilitation. J Sport Health Sci 2021; 10: 154-161 DOI: 10.1016/j.jshs.2020.11.005.
• 27 McPherson AL, Nagai T, Webster KE. et al. Musculoskeletal injury risk after sport-related concussion: A systematic review and meta-analysis. Am J Sport Med 2019; 47: 1754-1762 DOI: 10.1177/0363546518785901.
• 28 Nilsson M, Hagglund M, Ekstrand J. et al. Head and neck injuries in professional soccer. Clin J Sport Med 2013; 23: 255-260 DOI: 10.1097/JSM.0b013e31827ee6f8.
• 29 Arnason A, Sigurdsson SB, Gudmundsson A. et al. Risk factors for injuries in football. Am J Sports Med 2004; 32: 5S-16S DOI: 10.1177/0363546503258912.
• 30 Broglio SP, Lapointe A, O’Connor KL. et al. Head impact density: a model to explain the elusive concussion threshold. J Neurotrauma 2017; 34: 2675-2683 DOI: 10.1089/neu.2016.4767.
• 31 McCrory P, Meeuwisse WH, Echemendia RJ. et al. What is the lowest threshold to make a diagnosis of concussion. Br J Sports Med 2013; 47: 268-271 DOI: 10.1136/bjsports-2013-092247.
• 32 Guskiewicz KM, Mihalik JP. Biomechanics of sport concussion: quest for the elusive injury threshold. Exerc Sport Sci Rev 2011; 39: 4-11 DOI: 10.1097/JES.0b013e318201f53e.
• 33 Hagglund M, Walden M, Ekstrand J. Previous injury as a risk factor for injury in elite football: a prospective study over two consecutive seasons. Br J Sports Med 2006; 40: 767-772 DOI: 10.1136/bjsm.2006.026609.
• 34 Walden M, Hagglund M, Ekstrand J. High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury. Br J Sports Med 2006; 40: 158-162 discussion 158-162 DOI: 10.1136/bjsm.2005.021055.
• 35 Beaudouin F, Demmerle D, Fuhr C. et al. Head Impact situations in professional football (soccer). Sports Med Int Open 2021; 5: E37-E44 DOI: 10.1055/a-1338-1402.
• 36 Krutsch W, Hadji A, Tross T et al. No increased injury incidence in the German Bundesliga after the SARS-CoV-2 virus lockdown. Arch Orthop Trauma Surg 2022; 142: 1571–1578. doi: 10.1007/s00402-021-04060-2
• 37 Krutsch W, Memmel C, Alt V et al. Timing return-to-competition: a prospective registration of 45 different types of severe injuries in Germany’s highest football league. Arch Orthop Trauma Surg 2022; 142: 455–463. doi: 10.1007/s00402-021-03854-8
• 38 Ekstrand J, Hagglund M, Walden M. Injury incidence and injury patterns in professional football: the UEFA injury study. Br J Sports Med 2011; 45: 553-558 DOI: 10.1136/bjsm.2009.060582.
• 39 Bjorneboe J, Florenes TW, Bahr R. et al. Injury surveillance in male professional football; is medical staff reporting complete and accurate?. Scand J Med Sci Sports 2011; 21: 713-720 DOI: 10.1111/j.1600-0838.2009.01085.x.
• 40 Pappachan B, Alexander M. Correlating facial fractures and cranial injuries. J Oral Maxillofac Surg 2006; 64: 1023-1029 DOI: 10.1016/j.joms.2006.03.021.
• 41 Krutsch V, Gesslein M, Loose O. et al. Injury mechanism of midfacial fractures in football causes in over 40% typical neurological symptoms of minor brain injuries. Knee Surg Sports Traumatol Arthrosc 2018; 26: 1295-1302 DOI: 10.1007/s00167-017-4431-z.