REWIND to Sunday, November 3, 2013. It’s a Sunday afternoon and Everton played host Tottenham Hotspur in the Premier League.

On-loan Everton forward Romelu Lukaku was through on goal and attempting to round Spurs’ goalkeeper Hugo Lloris. In the process the striker’s knee clattered into the Frenchman’s head – resulting in the then 26-year-old being knocked unconscious.

Despite that, he was cleared to continue playing by the club’s medical team after a four-minute stoppage.

It’s the incident that Headway – a leading brain injury charity – and the PFA (Professional Footballers’ Association) highlight as a key moment in the way that concussion in sport is dealt with.

“The incident very much catapulted us into the campaigning of this issue and we’re very proud of everything that’s been achieved since then, both in football, rugby union and other sports to make people change their protocols at the elite level,” Headway’s Luke Griggs said.

John Bramhall, Deputy Chief Executive at the PFA, added: “The issue of concussion in sport has developed over the years, it’s becoming more and more of an area people are aware of. It’s always very difficult for players who feel physically okay to accept that they can’t play for a period of time.

“But it is positive, from the Lloris incident, the way that was dealt with. There have been some high profile incidents recently where players have been removed from the field of play and they’ve had to do it, which is a positive from our perspective.”

TIMELINE: A look at cases of concussion across different sports

Drag your cursor to the right hand side and click on the arrow to move to the next slide

Headway released a statement in the aftermath of the incident, saying Tottenham and then manager Andre Villas-Boas were guilty of an “irresponsible and cavalier attitude”.

Despite the aforementioned improvements, Griggs insists that the hard work must continue.

“We are always evolving our understanding of technicalities. Brain injuries are no different,” he said. “We do know a lot more now, particularly about the accumulative effect of repeated blows to the head and the affect that can have. We are becoming more aware now of what can happen in single incidents of concussions and head injuries.

“It’s no more of an issue now than it ever has been. What has increased is our understanding and awareness of what happens when you suffer a minor head injury. And as our understanding and awareness increases, sport must move with it and improve their protocols in order to better protect those who enjoy it on a weekly or even daily basis.”

Dr Michael Turner, who is leading a research project by the International Concussion and Head Injury Research Foundation, believes the issue of concussion in sport is only going to grow.

“It becomes more of an issue as we learn a bit more. The problem at the moment is we don’t have a clear idea of what the risk is, which is why there’s so much unknown about the condition.

“Before we accepted that concussion, or we thought at least, that concussion was a self limiting problem like rebooting your computer, you just have a concussion, your lights go out for a short time and once you’re rebooted again you’re back to normal and there’s been no damage. That can happen again and again and again. There’s now evidence that concussions can lead to long term problems and concussion is a common injury in a lot of sports.

“Players accept they’re going to face some injuries and at the end of time you may need a new knee or a new hip, but you can’t have a new brain, so if you’ve completely ruined it over the course of your sporting career and it starts to pack up during your 40s/50s then you’re in serious trouble.

“Once we’ve done a bit more research and had 10/20 years of managing concussion, we’ll be in a much better position to advise people what they should be doing if they sustain concussion.”

INFOGRAPH: What is concussion and who’s at risk?

Dr Turner, whose research started in January and will take at least three years to produce any “meaningful” data, admits its “very difficult” for governing bodies such as the FA or RFU to set suitable protocol on concussion currently.

“To educate people you have to explain to them what the risks are and if you don’t know what the risks are you tend to fall into two camps. You’re either a scaremonger by saying this is an incredibly dangerous sport or you’re a flat earth person by saying actually there is nothing wrong with the sport, we’ve been doing it for hundreds of years and there’s no evidence that you’ve got any trouble.

“It’s very difficult for governing bodies at this stage to advise people. All you can is say there appears to be a risk that you may suffer long term damage to your brain if you suffer concussion and the research we’re doing and other people are doing that’s as far as you can go at the moment.”

Griggs, who helps run Headway’s campaign #ConcussionAware, admits he is “worried what the long term impact will be of continually sustaining head injuries”.

“The bottom line is we don’t know how many are living with long-term brain injuries in general let alone suffering concussion,” he confessed. “Many people sift through the net and don’t get diagnosed and we think that’s very much the case for minor brain injuries like any other case of brain injury.

“For the majority of people that suffer one case of concussion, they will go on to make a full recovery assuming they get the required rest and don’t return to play before they are fully recovered.

“A small majority of people will have the symptoms prolonged and there may be complications that occur but we don’t know how many people each week sustain concussions and how many people more to the point maybe five, 10/20 years after playing are suffering from neurological difficulties as a result of accumulative effects of repeated blows to the head.”

INFOGRAPH: What are the symptoms and clues of concussion?

The campaign which focuses on raising awareness amongst grassroots and amateur clubs has already started to reap awards.

“We’ve had numerous people contact the charity to talk about how their seemingly innocuous minor head injury has actually made a dramatic impact on their lives,” Griggs explained.

“Some have gone on to suffer more severe brain injuries as a result of incorrect concussion protocols being observed or more not being observed.

“Once you have minor concussion or a minor head injury you need to make sure the brain has adequate to recover and to rest and if you have another blow to the head in the mean time you’re at risk of exasperating the seriousness of the original injury and causing yourself serious neurological damage.”

Griggs also stressed that grassroots players must take extreme caution when concussion is suspected.

“We cannot have a layman trying to make an assessment on whether someone is medically concussed or not and that’s why we cannot have people taking a chance and they’ve got to take this ‘if in doubt, sit it out’ approach.”

It is clear that a lot of progression has been made regarding concussion in elite sport. Mamadou Sakho being withdrawn from the League Cup final was a prime example of a greater understanding amongst coaches of the risk.

More research projects are taking place and can only further develop people’s understanding of the issue.

However, understanding the full complications and long-term impacts of concussion and getting the average ‘Sunday league’ player to understand the risks may still be a few years away.

By Callum Matthews

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