By Graham Ruthven
As a dazed Hugo Lloris staggered to his feet and returned to his goal, the Spurs supporters at Goodison Park applauded. The macho, hard-edged ethos of English soccer dictated that the French keeper's braveness be saluted. Spurs manager Andre Villas-Boas said as much after the game, praising Lloris for showing "great personality and character." But the response to Lloris' concussion was telling. It demonstrated the frankly reckless disregard for such injuries in the Premier League.
Lloris had suffered a heavy blow to the head, bearing the full brunt of Everton striker Romelu Lukaku's knee in an accidental collision, knocking the Frenchman into unconsciousness. Brad Friedel, the substitute keeper, was stripped and ready to replace Lloris, but despite his confused and disorientated state Lloris convinced the club doctors of his well-being, returning to the game for the remaining 15 minutes.
However, was Lloris' decision to continue play in such a state 'heroic' -- as it has been described -- or foolish? One caller to a radio phone-in show hailed him for being a "brave lad" and recovering "like a real man," while brain injury charity Headway condemned the club for showing an "irresponsible and cavalier attitude" to the keeper's health. The FIFPRO World Players' Union released a statement in response to the incident claiming Villas-Boas and his staff "failed to protect the goalkeeper by allowing him to see out the remainder of the match."
By keeping Lloris on the field in such circumstances, were Spurs effectively saying preserving a 0-0 draw on the road was more important than their keeper's health? It would appear so.
Current Premier League regulations offer a vague policy on head injuries, stating, "any player, whether engaged in a league match, or any other match or training, who having sustained a head injury leaves the field of play, shall not be allowed to resume playing or training until he has been examined by a medical practitioner and declared fit to do so."
Technically speaking, Spurs complied with this direction, but with no clarification of what a 'medical practitioner' or what 'fit to do so' constitutes, the guidelines are open to interpretation.
FIFA outlines that if a player is knocked unconscious he "should be immediately removed from play" and "urgently assessed medically." With Villas-Boas' confirmation that Lloris had entered unconsciousness, he affirmed Spurs had kept its goalkeeper on the field by ignoring FIFA guidelines. But while FIFA's stance might be a little more coherent, the Premier League's ambiguous regulations on concussion reflects a cultural ignorance of such injuries.
Boos rang from the Everton support as the Spurs medical staff took the best part of 10 minutes to treat Lloris. Ask a sample of British soccer fans and most will likely tell you that concussion, or symptoms of concussion, doesn't constitute a sporting injury. In a cosmopolitan and otherwise modern sporting sphere, where developments in sports science and physiology have improved understanding of injury and physical well-being, soccer remains largely ignorant of concussion and the effect it can have on players.
Research published by the British Journal of Sports Medicine concluded that most English soccer teams don't comply with international guidelines on concussion among players. The guidelines, set out by Consensus in Sport (CIS) -- a Zurich-based medical body focusing specifically on sport -- and advocated by FIFA, stipulate that all players must undergo cognitive assessment before the start of the season, and meet certain requirements before taking the field.
A study conducted in 2010 found that fewer than half of the Premier League clubs (of those that responded) carried out the required assessments. 28% of clubs admitted that they hadn't even heard of the CIS guidelines. Dr Jo Price, who led the research, added English soccer teams could be "potentially putting their players at risk."
There have been high-profile cases of concussion in English soccer. Former England captain John Terry was knocked unconscious in the 2007 League Cup final after receiving a hefty kick to the head from Arsenal's Abou Diaby. Another Chelsea player, Didier Drogba, was hospitalized with concussion after a clash with Norwich keeper John Ruddy two seasons ago.
But by and large English soccer still lags behind other sporting cultures when it comes to understanding the sincerity with which head injuries should be treated and regarded.
American sports appear, generally, better equipped to understand and treat head injuries. That could be attributed to a widespread education of such injuries in American sport. The issue has long been debated in the NFL, with several cases increasing public awareness of the issue.
Of course, soccer as a sport permits less natural contact than the NFL and gridiron football, but American soccer has followed the set precedent. Major League Soccer even has its own concussion protocol, effective as of 2011. These statutes demand that every player registered to the league must undergo strenuous testing before the start of the season, and will be referred to a neuropsychologist for further examination before returning from such an injury.
Lukaku, the player who smashed into Lloris on Sunday, found himself on the blunt end of a collision earlier in the season, clashing with a defender as he scored the winner in a 3-2 win for Everton over West Ham. Replacing the Belgian striker would have reduced Everton to ten men, with head coach Roberto Martinez having used all three of his substitutions, and so Lukaku was forced to stay on the field.
Lukaku was later asked what he could recall of the goal. "Nothing," he replied, confused. "I didn't even know that I scored. I didn't remember what happened for a couple of seconds, and then I woke up, and they said I scored."
CIS guidelines also state that players should not play any contact sport for at least three weeks after suffering a concussion. Lloris was back in his goal within minutes. Goodison Park should have held its applause.
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Graham Ruthven is a soccer writer based in the UK. He has written for the New York Times, ESPN, MSN Sport and Scottish TV, among others. Follow him @grahamruthven.