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How long will it take for Sami Khedira to get back on the pitch?

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Gerry discusses concussions.

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Gerry has worked in football for many years as a club physiotherapist and has a Masters in football rehab, currently about to complete a second masters in Sports Medicine.

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The downside from the anticipated victory against Cornella was the head injury sustained by Sami Khedira. After colliding with Cornella's David Garcia, the German international was substituted and spent the night in hospital; a practise which has now become routine following a concussive head injury. With concussion injuries of any kind, the danger period can often be in the hours that follow after the actual injury has been sustained as opposed to at the time the contact takes place. Since head injuries can potentially be fatal, the need for a period of observation is essential.

Thankfully the management of head injuries in football is now moving with the times. After the injury, Sami would have had a full neurological examination and scanned for signs of brain injury and internal bleeding.  Although having now been discharged from hospital, his condition will be monitored over the next few days. The club statement issued after the match read:  'Following scans carried out on Sami Khedira by the Real Madrid medical services, a concussion injury has been diagnosed'.

This went on to add that Sami would remain under observation for the night after the game as a precaution. In reality, though, the injury will be monitored for a lot longer than the 24 hrs reported, since the effects of concussion can remain for several weeks and often may not be completely obvious at the time of the actual injury.

Symptoms of concussion can include headaches, dizziness, loss of memory and balance, disorientation, nausea and may even affect speech. Often, symptoms can linger long after the expected recovery time has passed.   Concussive head injuries are frequent in football and these are often accompanied by associated neck injuries.  Although the concussion aspect is usually well managed, untreated associated neck injuries can affect a player's heading ability; so nowadays it is important to exclude these as well.

Players are no longer rushed back into action as they were in the not-too-distant past, and FIFA's medical committee are actively involved in administering return to play protocols and treatment guidelines following head injury. The Zurich Consensus on Head Injury and Concussion in Sport (2012) defined concussion as a 'complex pathological process affecting the brain, induced by biomechanical forces'. In other words, an injury caused by a blow to the head with symptoms evolving over a number of minutes, hours, or even days.  Secondary concussion (or second impact syndrome to use the correct title) occurs when players return from head injuries too early, and leads to a recurrence of symptoms.

In the days before secondary concussion was recognised and knowledge of head injuries wasn't as extensive as it is today, pressure was often brought on players to return to play before the symptoms of concussion were fully resolved; thus risking further trauma. Apart from the obviously serious head injuries involving unconsciousness, it is often thought that players are fit to return to play within a few days of receiving a concussion injury. Normally an average concussion injury takes roughly 7 - 10 days to fully resolve provided no complications occur; however, this can vary and may take either a matter of days or even last longer than a few weeks.

There is no mandatory exclusion period in football following a head injury; concussion is a symptom-driven condition and the recovery time varies according to the severity of the symptoms. So instead of everyone having to sit-out a mandatory three-week period, individual responses are taken into consideration. Return to play is via a graduated rehab protocol which begins with complete rest and progresses to light aerobic activity, followed by non-contact light training which includes some football-specific work.  It is essential that players are symptom-free at this point before being able to progress to the final stage of the process, which is normal full-contact football training.  Players returning from a concussion injury are only allowed to progress to the full contact stage after medical clearance has been obtained to allow them to participate fully in normal training activities.

Having been released from hospital and without any apparent ill-effects at the moment, it is conceivable that Sami Khedira could well be involved in this weekend's forthcoming fixture against Celta Vigo. However, his condition will be monitored over the next couple of days and further checks are likely to be carried out. Only when Madrid's medical team are 100% satisfied that Sami has made a full recovery will he be allowed to return to play.