At tonight's quarterfinal, a player exhibits signs or symptoms of a possible concussion. How will they be evaluated on the pitch?

The Football-Specific Standardized On-Pitch Concussion Assessment Protocol (FOCUS) was published in July 2026 in JAMA Neurology.

It was developed through a FIFA-led international Delphi consensus process involving experts from all 6 football confederations.

The primary objective of FOCUS is not to diagnose concussion but to determine whether a player exhibits any signs or symptoms that raise suspicion and would require off pitch assessment.

Additional Information

The 11 FOCUS Domains

1. Player medical history (Touchline/Pre-assessment): Know if the player has had previous concussion, previous head impact within the same match, previous head injury assessment within the same match, or is on anticoagulation therapy. Any of these lowers the threshold for concern.
2. Mechanism of injury (Touchline/Approaching player): Consider whether the head impact was a high-risk mechanism and whether the player is lying motionless with suspected loss of consciousness.
3. Visible signs (Touchline/Any time): Two tiers:
   • Immediate substitution signs: Floppy/no protective action, impact seizure, tonic posturing, motor incoordination, vomiting, persisting abnormal emotional/behavioral response, indicators of skull fracture 
   • Lower threshold signs (continue assessment): Superficial face/head injury, blank or vacant look
4. Level of consciousness (On pitch): Assess using modified ACVPU scale — ask the player about recollection of the head impact event; check for confusion and slurred speech. If not fully alert and coherent ? immediate substitution.
5. Cervical spine assessment (On pitch): Neck pain at rest, midline tenderness, restricted active ROM, unexplained limb strength or sensation abnormality ? immediate substitution.
6. Symptoms (On pitch): Ask about headache/pressure, dizziness, "not feeling quite right," drowsiness, disorientation, balance difficulties, difficulty following instructions, nausea, blurred/double vision, feeling slowed down, sudden hearing loss. Any symptom not explained by another cause ? immediate substitution.
7. Orientation (On pitch): Five football-specific questions (venue, which half, who scored last, last opponent, last match result). Any inappropriate response ? immediate substitution. These are similar to the Maddocks questions used in American football assessments.
8. Balance (On pitch): Tandem stance (dominant foot in front, eyes closed, 20 seconds; may repeat once). Any abnormality or reported unsteadiness ? immediate substitution.
9. Proprioception (On pitch): Finger-to-nose test with eyes closed, alternating hands. Any abnormality ? immediate substitution.
10. Oculomotor function (On pitch): Smooth pursuit (track target side-to-side and up-down without head movement) and convergence (track target moving toward nose). Check for nystagmus and pupil abnormalities. Any abnormality ? immediate substitution.
11. Activity-based assessment (Touchline — only if no issues identified earlier): Sprint 5 m forward, 180° turn left, sprint 5 m, 180° turn right. Any visible signs, symptoms, or abnormality ? immediate substitution.

References

Peek K, Massey A, Connolly R, et al. Football-Specific On-Pitch Concussion Assessment Protocol—International Consensus Recommendations. JAMA Neurol. Published online July 01, 2026