In the world of sports, football is unique because of the purposeful use of the unprotected head for controlling and advancing the ball. This skill obviously places the player at risk of head injury.

Head injury can be a result of contact of the head with another head (or other body parts), ground, goalpost, other unknown objects, or even the ball. Such impacts can lead to contusions, fractures, eye injuries, concussions, or even, in rare cases, death.

Correct heading of the ball can rarely be accountable as a cause of acute injury; however, the long-term effects of this repetitive trauma are yet to be determined.

It is thought that the goalkeeper is the position most at risk for head injury and concussions in particular.

Players who exhibit signs or have symptoms of possible head injury must immediately be removed from play and medically evaluated. Unconscious players should be assumed to have a cervical spine injury, and quick attention should be made to address their airway, breathing, and circulatory status, while maintaining spinal immobilization.

Unconscious and unresponsive players should immediately have their cervical spine stabilized.

Immobilization of the cervical spine often complicates airway management in an injured athlete because the cervical spine is ideally splinted in a neutral position. This is most often accomplished by positioning someone at the head of the supine athlete to hold the head in a neutral (in-line) position. Unfortunately, this necessary procedure allows for less access to the airway, with less physical space for the physician to maintain or control the airway at the head of the athlete [1].

Players that have suffered a loss of consciousness should be referred to the emergency department (ED) for further evaluation and head CT scan.

Football is a sport not traditionally identified as high risk for concussions, yet several studies have shown that concussion rates in football are comparable to, and often exceed those of, other contact sports [2].

In conscious patients, a quick survey of the ABCs should be followed by evaluation of spinal tenderness and a neurologic assessment of the upper and lower extremities. Unstable patients should be transported immediately to a medical facility for additional imaging and management.

Symptoms may include headaches, nausea, dizziness, photophobia, fatigue, and difficulty with concentration and memory. Outward signs include loss of consciousness, confusion, amnesia, loss of balance and coordination, and personality changes.

Loss of consciousness (LOC) is not required for a diagnosis of concussion. Only approximately 10% of sports-related concussions include LOC.

There are several pocket guides to help the physician to quickly diagnose a concussion on the field; we normally use the one from the FIFA medical group (Fig. 5.1).

Thorough physical and neurological examination, followed by a quick questionnaire as exampled above, normally provides the diagnosis.

Concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces. Direct or indirect transmitted forces due to rotational and/or acceleration-deceleration forces to the brain cause changes at the cellular environment.

All concussed players should be removed from the contest and should not return to play that day. A graded return-to-play guideline should be applied to each athlete, allowing progression based on the individual.

Each individual should be rested physically and cognitively until symptoms resolve. Upon resolution of symptoms, athletes can progress to light aerobic exercise, followed by sport-specific exercise, then non-contact drills, followed by full-contact practice, and eventual return to unrestricted play.

Neck injuries are much less common than head injuries in football. Most are mild injuries (mild sprains, abrasions, and small lacerations).

The mobility of the cervical spine allows for much of the applied forces of the neck to be dissipated through lateral bending, flexion, and extension.

These forces are effectively absorbed through the paravertebral muscles and intervertebral disks. When these mechanisms fail, serious injury occurs.

Most serious neck injuries resulting in fracture or dislocation of the cervical spine usually occur as a result of a fall.

When approaching an athlete complaining with neck pain, the priority is to stabilize cervical spine to prevent further injury.

The next step is to establish the mechanism of injury if it was not witnessed. The following questions will then have to be answered:

The sequence of the questions is fundamental. A negative answer to any of the questions establishes the obligation to cervical spine immobilization and to proceed to the ED for further evaluation (X-ray, CT scan, etc.).

The example above, frequent in recreational and professional football according to the Canadian C-Spine rule, constitutes a “dangerous mechanism of injury” that one could compare to diving. This and the presence of upper limb neurological signs would make C-spine immobilization and radiological investigation mandatory (Fig. 5.2).

Although we consider it a good tool, the limitation of the CCR is the fact that the majority of sports-related mechanisms of injury could be considered dangerous mechanisms (force equal to or greater than falling from a height >3 ft), which would require imaging for most suspected spinal injuries in sports. Thus, personal clinical judgment and experience still play a vital role in assessing sideline spinal injuries, keeping in mind that if a serious spinal injury is ever suspected, appropriate stabilization and transportation for definitive care should be implemented [3].

In the last years, shoulder injuries have represented an increasing health problem in football players. The modern football has been characterized by high-speed game, “dangerous” tactical solutions such as pressing and marking, and augmented number of legal and illegal physical contacts.

It is always helpful for the medical staff to watch the mechanism of injury. When dealing with shoulder injuries, this assumes a capital importance in order to rapidly perform a diagnosis.

The first question to answer is: What was the position of the arm at the time of trauma? Was it in abduction or in adduction?

One should then proceed to do a careful inspection and palpation of the shoulder girdle on the field.