Concussion once again reared its ugly head at the FIFA World Cup in Russia, four years on from the highest profile case in the sport's history. Are FIFA and its member nations serious about tackling the issue plaguing the beautiful game?

Tando Velaphi – Perth Glory's gallant goalkeeper – was lying flat on the turf, in visible pain on a dreary Saturday night in Wellington.

It was the 63rd minute of the Wellington Phoenix's A-League encounter against the Glory at Westpac Stadium, in which the home side went on to win 2-1. Velaphi was down in need of treatment after copping an accidental knee to the head from Glory forward Joel Chianese, his head snapping back upon impact like a boxing speed bag.

And yet, after a few questions from the team doctor, Velaphi was allowed to continue despite the worrying head knock. In other sports, he would've been required to leave the field to be assessed for a concussion. But in football this is an all too familiar occurrence.

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Head injuries and concussion in football are grey areas. From New Zealand's domestic grassroots leagues to the FIFA World Cup; there are issues. But who is prepared to take a lead tackling football's ugly little secret? And what do FIFA and New Zealand Football plan to do to address the problems?

In the 74th minute of Morocco's first match of the World Cup against Iran in Russia, Morocco winger Nordin Amrabat was substituted after a clash of heads, in which he suffered memory loss and had to spend the night in hospital. "From the first minute, 'til I wake up in the hospital. I think five, six hours, gone. Totally gone," Amrabat later said about his memory loss. "When you think about it, it is a little bit scary."

It was an alarming echo of comments made by Christoph Kramer after the German midfielder collapsed during the last World Cup final in Brazil, perhaps the highest profile case of concussion and head injury in the history of the sport.

Morocco's Nordin Amrabat on the ground after a head clash during their World Cup match against Iran. Photo / Getty
Morocco's Nordin Amrabat on the ground after a head clash during their World Cup match against Iran. Photo / Getty

"I don't know anything from the first half," Kramer said afterwards. "How I got to the changing rooms I do not know." Kramer continued to play for 14 minutes after the initial collision with Argentina defender Ezequiel Garay, eventually getting replaced after slumping to the turf in the 31st minute.

It made the decision to allow Amrabat to play in Morocco's second match against Portugal – five days after being in hospital, despite FIFA's policy that players shouldn't play six days after getting concussed – even more concerning. "I am my own doctor," Amrabat said after Morocco's 1-0 loss to Portugal. "Hopefully nothing will happen to me in the long term."

Morocco manager Herve Renard defended his decision to pick the player, even praising his supposed bravery: "He's a warrior; he wanted to play. It's because his spirit is amazing and I was lucky to have a player like this." Morocco escaped any sort of punishment from FIFA.

Following the Kramer incident at the 2014 World Cup final, FIFA strengthened its concussion protocols regarding players returning to action after head collisions. But they aren't hard and fast rules, just guidelines. "They have a policy it's pretty clear but in their policy they rely on the team doctors to [enforce it]," says Dan Exeter, a sports and exercise science physician from Axis Sports Medicine. "I think you've gotta ask yourself, what is gonna motivate people to do the right thing if you can't rely on everyone to follow the protocols.

"FIFA are very happy to significantly fine member nations for things such as wearing items of kit which contravenes with their sponsorship agreements, so maybe they need to take a similar approach when people don't follow their [concussion] policy."

Morocco and Amrabat's disregard for FIFA's protocols sparked criticisms from the world player's union and brain injury experts who questioned the purpose of the governing body's guidelines, as well as their appetite to tackle the issue. "Here we go again," FIFPro's head of communications Andrew Orsatti wrote on Twitter. "Four years on from debacle of the last World Cup, where several players didn't receive adequate care, football has not made sufficient progress in concussion management. Repeated calls to implement world-class standards all overlooked."

Christoph Kramer of Germany receives medical treatment during the 2014 FIFA World Cup final. Photo / Getty
Christoph Kramer of Germany receives medical treatment during the 2014 FIFA World Cup final. Photo / Getty

Peter McCabe, the CEO of brain injury association Headway, said it was a stain on the sport itself: "The decision to allow this player to take to the field not only put his short and long-term health and career at risk but it also set an appalling example for the millions of fans and players around the world."

So what are FIFA and its member nations doing to deal with the growing concern of concussions and head injuries in football? Quite a lot says Exeter, who has followed FIFA's work in the space closely. "What FIFA have done well is that they've continued to support research in development of concussion protocols. The gold standard concussion protocols wouldn't exist without a lot of FIFA support. They've been instrumental in that." But the protocols are far from perfect he says – the events of this past World Cup being a stark reminder.

Research by a team of doctors in Canada after the 2014 World Cup revealed that two-thirds of head collisions during the tournament were not followed by players being assessed by medical professionals on the sidelines. The study, published in the Journal of the American Medical Association, also noted that the few assessments that were carried out were too brief, with the longest stoppage of play being just 180 seconds. "It doesn't matter whether they had a concussion – my point is that they should be assessed," said Michael Cusimano, a neurosurgeon and co-author of the research. "It is almost impossible to do an assessment in that short a time."

Nothing has been done to remedy football's laws of the game since the release of the damning study four years ago. Exeter agrees that having the ability to assess players is critical. "Lots of sports have done that very very well and I think it's very difficult to make an assessment under the current football rules. In order to do that, it's gotta be palatable to the sport. So you can't have a situation where the game is significantly impeded by someone trying to do something for player welfare. You're gonna have to have a concussion substitute ... other sports have that."

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Morocco winger Nordin Amrabat in action against Portugal, five days after being in hospital and suffering from memory loss. Photo / Getty
Morocco winger Nordin Amrabat in action against Portugal, five days after being in hospital and suffering from memory loss. Photo / Getty

Former players like England and Newcastle United great Alan Shearer have been outspoken supporters of temporary substitutions to allow players to have a proper concussion assessment, while not penalising a team for losing a player. However, FIFA have been notorious for its conservatism when it comes to tweaking the laws of the game. Their tentativeness within the video refereeing space is a prime example.

New Zealand Football medical director Mark Fulcher says it's as much about changing the culture in football as it is about creating and fine-tuning the protocols around concussion and head injuries. "What we're trying to do is change the culture," says Fulcher. "I think there's a perception amongst footballers that maybe concussion in football is not common, or it's not an issue in football, it's a rugby problem. That's not true. We all need to be aware of this."

Ultimately, FIFA's member nations like NZ Football will follow FIFA's lead on creating rules and policies around the issue. "It's difficult to make a rule," says Fulcher. "So if you look at any of the other major sporting codes outside of rugby and rugby league where concussion is much more common, they basically rely on the participant to do the right thing. So it's individual responsibility. So we're reliant on the laws of the game and there is no rule that says that if you're concussed, you cannot play.

"Rugby for example, where concussion is three times, four times more common, they have mandated rules, but again, there's a level of infrastructure that's required to enforce those rules that we just don't have."

As the science around concussion and head injuries becomes more and more concrete, it will become increasingly difficult for FIFA and its member nations to ignore the dangers that the sport can present to its players. "I think there's a culture change that's happening," says Fulcher. "[But] it's fair to say there's a bit of work to be done."

Football – as showcased by Neymar, Brazil's whinging winger, throughout the World Cup in Russia – has a long ingrained tradition of acting and pretending, rather than facing the truth. FIFA president Gianni Infantino was asked before the World Cup final earlier this month about the governing body's intention to tackle the issue of concussion and head injuries. In the wake of multiple incidents during the tournament, Infantino – who took over for disgraced former president Sepp Blatter – said FIFA will look into whether additional efforts are necessary to "protect the health of the players".

"Concussions are a very serious matter that we take very seriously," Infantino said. "That is why we have evaluation and recommendation and expert advice.

"Can we do more? Of course," he said, without expanding.