Morgan Brian Collision A Reminder That Concussion Protocol Still Needs Work

Julie Foudy, Kate Markgraf and Kristine Lilly break down the United States' 2-0 win over Germany and preview Wednesday's matchup between Japan and England.

VANCOUVER, British Columbia -- The sight of Morgan Brian prone on the turf after a clash of heads with Alexandra Popp left a lot of people wondering if a bright, young star of American soccer, not to mention one of Germany's ascendant talents, could continue in a World Cup semifinal. It left others to wonder if either should.

Could and should. In the small difference between those two words rests an unsolved and urgent puzzle for the sport of soccer.

After a delay of about four minutes following their first-half collision Tuesday, during which time both players received treatment on the field and the German medical staff stanched a bloody wound on Popp's head, each player walked to the sideline under her own power. Almost as soon as they got there, the referee waved them back into play.

Everyone in the scenario might have acted exactly according to protocol. Each part of the sequence might have ended in the correct decision, ones that reasonably gave primacy to safety even against the importance of the contest to consenting adults and their respective teams. Maybe that is exactly what happened.

Jean-Yves Ahern/USA TODAY Sports

Despite a head-on-head collision Tuesday, Morgan Brian did not suffer a concussion and therefore does not need to pass any tests to play Sunday against Japan.

"I have absolute faith and trust in our medical team to do the right thing," United States coach Jill Ellis said. "And they assessed her on the field, they assessed her at halftime. They go through a strict regimen of protocols that is set forth by U.S. Soccer. You know, she was fine, no symptoms."

"But no, I would never question our doctors; I think they do the right thing."

A U.S. Soccer spokesperson reiterated to espnW during the team's travel day to Vancouver that the team's medical staff saw no symptoms of concussion from Brian, either on the field at the time or at halftime when she was examined again, in both cases by Dr. Bojan Zoric.

According to the United States, Brian did not suffer a concussion. And in one sense, that's the end of the news.

Brian, who said she was fine after the game, will continue to be monitored, but only in the sense of reporting or showing symptoms. She doesn't need to pass tests to play.

Had a concussion been suspected from her actions or responses during the initial evaluation, U.S. Soccer's stated protocol would have been to remove her from the game and proceed with further evaluation, known as the "SCAT3" test involving cognitive and physical measures and also employed by the NFL. Athletes are asked, among other things, to listen to a list of words and numbers and recite them back, sometimes in reverse order, recite the months backward and stand in a variety of stances to test coordination and balance. These results can be compared to baseline testing undergone by all U.S. Soccer athletes before competition. If a concussion is suspected, that in turn triggers another protocol for returning to the field once asymptomatic.

Again, according to U.S. Soccer, Brian didn't demonstrate any symptoms. She didn't suffer a concussion. She played the remainder of the game without incident.

It should represent a satisfactory conclusion. It does when a player appears to tweak a knee or ankle, receives treatment and then runs back on the field to continue playing. The knee is fine. We can see that for ourselves. Yet when it comes to head injuries, whether in the World Cup or a weekend youth league, there is always something unsatisfactory about the resolution of an incident because we understand so little about what damage might have been done.

Jean-Yves Ahern/USA TODAY Sports

U.S. midfielder Morgan Brian remained in Tuesday's semifinal against Germany after being assessed by U.S. Soccer's medical staff.

We have to take someone's word for it that Brian is fine. We don't really know what it would mean if she wasn't.

It is unsatisfactory not because we know it should have played out differently in any but the most reckless cases, some of which were on display in last summer's men's World Cup when players staggered and stumbled in dazes, but because there is so much we don't know and so many potential conflicts of interest.

And here's the thing: Brian is as familiar as almost anyone with why this issue is a big deal and why it needs to be talked about it, even if in the absence of a concussion, it frustrates the team and fans tired of the subject. As the 22-year-old solidifies her place as a future star of the national team by playing like one right now, even in what is not her natural attacking role, one of her closest friends was forced to retire from soccer and basketball because of multiple concussions.

Becca Wann was a mid-major standout at the University of Richmond who slipped through the recruiting cracks but caught enough eyes with her play in college to first earn a look from the national system and eventually a place on the same roster as Brian and Julie Johnston for the American team that won the 2012 Under-20 World Cup. Big, strong and physical, she was a productive rebounder on the basketball court and even better aerial asset in soccer. But after a concussion sustained in a Richmond game as a result of a collision of the same sort as Tuesday night's, and despite wearing protective head gear at the time, Wann was advised to give up soccer.

Eventually, Wann -- who at one time looked destined to play at the pro level in either sport -- made the same decision about basketball.

As a player, you want to keep playing. So you're going to tell yourself in the moment, with all the adrenaline, that nothing is wrong. So that's the hard part.
Morgan Brian

By her own count, Wann was diagnosed with four or five concussions before retiring. She acknowledged there might well have been more that went undiagnosed. After the last one, the severe headaches lingered for days. She avoided bright lights, sought out darkness, even when doing something as simple as cooking.

"We don't really know what the long-term effects are," Wann said of her decision shortly after she stopped playing soccer. "Which is why I think pulling the plug now is the smart thing to do, because no one knows what the next one will do."

We don't know. And when even doctors who make it their focus don't understand the brain in anything close to the same way their peers do ligaments or bones, it is all the more difficult for the rest of us to figure out if head injuries in women's soccer, which trails only football in their frequency among high school athletes, are a problem or a crisis.

The director of the University of Michigan's NeuroSport program who has consulted with three of the four major men's professional leagues on concussion-related issues, Dr. Justin Kutcher spoke to espnW around the time of Wann's retirement.

"We say things like, 'Concussion is not a knee injury, it's not an ACL,'" said Kutcher, who was not involved in Wann's specific case. "I think that has been repeated so often that people have lost what it means. Really stop and think about that, and what that means is the complexity in front of you of each particular [brain] injury and each particular individual is tremendous, to the point that all these statements people make about what we should and shouldn't do is really not based in any real science."

Which brings this back to Brian, who it could be argued has been as valuable for the United States in the past two rounds as any player on the field, both in what she does as the link between the back line and the players ahead of her and in giving Carli Lloyd the freedom to become the likely Golden Ball winner if the United States beats Japan in the final Sunday. Lloyd deserves that, but it is no coincidence that the two best offensive performances for the Americans came with Brian alongside her in the midfield.

Courtesy of University of Richmond

Becca Wann was a two-sport athlete at Richmond who also competed for the U.S. soccer team that won the 2012 FIFA Under-20 Women's World Cup.

What would the United States have done against Germany had Brian wobbled as she walked to the sideline or struggled to remember what city she was in? Would it have been able to remain in the formation that knocked Germany off kilter and created the possession that eventually led to goals? We can't know, because when Ellis and the coaches on the sideline put up their thumbs in a silent question, the medical staff responded with the same gesture. Brian, they indicated, was good to stay in the game.

Perhaps this was the instance when neither Brian nor Popp, save for some stitches in the case of the latter, came out the worse for wear despite extreme contact.

And if every collision requires players to be removed from the field, it is going to fundamentally change the nature of international soccer. But the status quo struggles to hold.

Brian is the youngest player on the American roster, but her whole life had been about getting to a night like Tuesday. Hours spent crisscrossing interstates to train with the most competitive club team possible. Dances, family gatherings and nights with friends on Georgia's St. Simon's Island skipped so that she could play in tournaments across the country or travel the globe to represent that country. All with the aim of honing the talent, not to mention passion, that put her in a World Cup semifinal.

With most injuries, the mind might be willing, but the body has the final say. It is far trickier when the body remains functional and the mind can't check competitive instincts.

Asked a little more than a year and a half ago what she would do in a hypothetical situation that mirrored the one that presented itself in reality Tuesday night, a game for her country with the biggest of stakes, Brian admitted she probably would not be able to pull herself out if she felt something wasn't right after a blow to the head.

"As a player, you want to keep playing," Brian said at the time. "So you're going to tell yourself in the moment, with all the adrenaline, that nothing is wrong.

"So that's the hard part."

She also acknowledged at the time that she'd had "a couple" of concussions. Just not as many as her friend.

So it is left to the team's medical staff, in hectic moments on the field with a referee looking to resume play and coaches mulling substitutions, to make a call. They are trained to do so. They have access to each player's history, including the baseline testing all U.S. Soccer players go through.

But no decision any player or referee makes on the field ever comes with such potentially long-term consequences.

Even if it produced the correct result in this instance, that is an uncomfortable and unsatisfactory reality.

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